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Fields that you must complete are marked with this symbol: Required

Reporter Type

Reporter Type
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If you are reporting about your own suspected reactions to a medicine and you are a healthcare professional, please fill in the 'reporter type' as healthcare professional.

Contact Email

Please note this email address has previously been registered with the Yellow Card site, you can login here. Logging in will save you time and you can then keep a track of submitted reports.

Please provide an email address to receive notifications about your submission.

1. Reporter Details

Fields that you must complete are marked with this symbol: Required

Contact Method

Contact Method

Address

Address

Telephone Number

Telephone Number

Form actions Step 1. Reporter Details