About Us
Services
Contact
Pharmacovigilance
Locations

Pharmacovigilance

Please enable JavaScript in your browser to complete this form.

Administered Treatment Do

Name *

First

Last

Email Address *

Phone Number *

Date of birth *

Sex *

Male
Female

Who is reporting? *

I am a patient
I am a healthcare professional
I am a family member/acquaintance of the patient

Product (Medication) *

Health Registration *

Batch Number *

Prescribing Doctor *

Doctor´s Name

Prescribed Dose and Dosing Schedule *

Ex: 1 tablet every 8 hours

Administered Dose *

Ex: 50 mg, 1 tablet…

Route of Administration *

Ex: Oral, Injectable, Topical…

Description of the Adverse Reaction *

Describe symptoms and progession in detail…

Treatment Start Date *

dd/ mm/ yyyy

Adverse Reaction Start Date *

dd/ mm/ yyyy

Did you take any medication 24 hours before starting the new treatment? *

Yes
No

If your previous answer was yes, which medication was it?

Do you authorize us to contact you for additional information about your report? *

Yes
No

Address

3rd street 5-31, Zone 16, Colonia Lourdes, Las Rotondas Residential

Facebook
X
Instagram
YouTube

Pages

Schindler Innovation

About us
Services
Contact
Pharmacovigilance
Locations

Contact

(502) 2426 – 3548

Email

atc@schindlerinnovation.com

farmacovigilancia@schindlerinnovation.com

Schindler Innovation

♿

Accessibility Assistant

Would you like to activate the voice assistant for blind or visually impaired users?

Quick Access: Press the F key for Yes, or the J key for No.