Questionnaire for a patient or other person

1. Describe your problem
Problem Description*
- I developed an undesirable reaction after using the medicine;
- The medicine is not effective
- I discovered a counterfeit drug;
- I need advice on drug interactions when taking the drug (s) produced by Samson-Med LLC in combination with any other drugs;
- I need advice in connection with the method of use of the drug, not described in the instructions for medical use;
- I need advice on overdose;
2. Personal Information
Are you*
- a patient?
- a relative of a patient?
- a representative of a patient?
Phone*
Email*
Where do you live?

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5. Experience of taking the drug before the development of an undesirable reaction
Please tell us about the experience with this medicine*
- The medicine was used for the first time
- The medicine was used previously, no adverse reactions were noted
- The medicine was used previously, there were similar adverse reactions
6. Sample of the medicine
Is it possible to provide for examination samples of the medicine that caused the adverse reaction?*
- Yes
- No

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Accepted file types: jpg, jpeg, pdf, png, gif, bmp.
You can add up to 4 files. Please use JPG or PDF for images and documents.
Data Use Consent*
- I hereby give my consent to receive, process, store and transfer my (and my patient) personal data to the authorized state bodies of the Ministry of Health of Russian Federation and Roszdravnadzor
Email
This field is for validation purposes and should be left unchanged.

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1. Describe your problem