Name

E-mail address

Telephone number:

Product:

Event description:

Personal data will be kept confidential, in accordance to Lei Geral de Proteção de Dados and local legislation.

Our Customer Service team might need additional information to proceed with your report. If necessary, do you allow our customer team to contact you trought the e-mail address and phone number provided in this form?

I agree to provide my personal data under the confidentiality terms above and I authorize BIOMM’s pharmacovigilance team to contact me in case additional information is required.

Δ