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Adverse Reaction Form

If you have any questions about how to identify an adverse event with any of our medical devices, please contact us at farmatec@sophia.com.mx and/or fill this form.

Initials

Date of Birth

Gender

Country of Residence

Product Name

Expiration Date

Are you still using it?

Lot No.

Adverse Event Presented

Date when suspected reaction began

Date when suspected reaction ended

Detailed description of adverse event

Name

Relationship with Patient

Phone Number

Email Address

If you wish, you can attach images or files with your report.

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