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若是您产生不良事务，，，应实时征询医生，，，同时请您填写不良事务/反映汇报表，，，也能够拨打药品注明中热线电话汇报不良事务/反映。对于您汇报的不良事务/反映，，，在此暗示感激！祝您和您的家人身段健康！
4.隐衷注明

william威廉亚洲官方会遵守隐衷法，，，对您及您上报的信息全程保密，，，请您安心填写！

患者信息

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诞生日期*

省份*

处方医院*

用药原因*

疑惑药品信息

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疑惑药品*

屋尘螨变应原制剂（安脱达）

螨变应原皮肤点刺试剂盒（安刺）

利丙双卡因乳膏

黄体酮注射液（II）（william威廉亚洲官方欣）

醋酸甲地孕酮口服混悬液（美适亚）

注射用人成长激素（赛增）

人成长激素注射液（赛增）

金培成长激素注射液（william威廉亚洲官方增）

注射用人促卵泡激素（william威廉亚洲官方恒）

人粒细胞刺激因子注射液（赛强）

注射用醋酸奥曲肽（金迪林）

醋酸曲普瑞林注射液

外用人粒细胞巨噬细胞刺激因子凝胶（金扶宁）

注射用醋酸西曲瑞克（william威廉亚洲官方捷）

重组人促卵泡激素注射液（william威廉亚洲官方恒）

注射用伏欣奇拜单抗（金蓓欣）

替勃龙片（william威廉亚洲官方蓓）

绒促卵泡激素α N02注射液（william威廉亚洲官方佳）

地诺孕素片

盐酸托莫西汀胶囊

药品上市许可持有人*

出产批号/规格*

不良反映名称

汇报者信息

汇报者*

汇报者联系方式*

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其他

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