At Vitaline, the safety, quality and effectiveness of our products is paramount. Therefore, if you observe any adverse effects after using any of our products, please contact us through the following communication channels:

WhatsApp : 989-152-298

Phone : (511) 208-9200 Extension 503

Email : farmacovigilancia@vitaline.com.pe

Or complete the following form:

Note: Remember that, by completing your data, you are accepting that a member from our team will contact you to follow up on your report.

Data of notification agent

Physician Patient Pharmaceutical Chemist Other Health professional

Do not allow follow-up

Name Address E-mail Country of origin

Telephone number Fax number

Data of patient

Patient's first initial

Male Female

Pregnant?

Yes

No

Date of birth (dd/mm/yyyy)

Suspect drug product(s)

Name of active ingredient Batch No.

Dose

Start date of treatment (dd/mm/yyyy)

End date of treatment (dd/mm/yyyy)

Physician's indications

Concomitant indications/other drug products used at the same time

Adverse effect(s)

Start date of the event (dd/mm/yyyy)

Description

Outcome

Recovered

Not yet recovered

Unknow

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