Качество препаратов

Questionnaire about the quality of our drugs

1/3Information about the drug

Name of the drug^*

Release form^*

Serial number^*

Expiration date^*

—

Does the appearance of the drug correspond to the instructions

Yes No

Description of the discrepancy^*

^* — required fields

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2/3Source of information

Last name^*

Name^*

Patronymic

Address

Phone^*

E-mail^*

Where the drug was purchased

^* — required fields

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3/3Contact Information

Date of notification of the complaint to the Quality Department

Account

Last name

Name

Patronymic

Address

Phone^*

E-mail^*

Comments

^* — required fields

Consent to

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