Report an adverse reaction

PATIENTS and/or health
report here:
Patient information

Name

Date of birth

Gender
MaleFemale

Data for Suspicion of an Adverse Reaction

Date of the beginning of the reaction

Description of the Suspicion of an Adverse Reaction

Information about the suspected medicine

Name of the medicine

Date of the beginning of treatment

Administration route

Dose

Lot number

Informant data

Full name

Phone number

Email

City/State

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Health professionals can also report here

Download the OfficialFormat by COFEPRIS

Fill the format with the solicited data (3 sheets long)

Save the changes and upload the file here:

I have read and accepted the terms of privacy..