Reporting person (compulsory) -----Chose-----DoctorPatient (carer or legal guardian)PharmacistPharmacy technicianNurse/MidwifeOther Reporting person Reporting person Choose the prefered way of contact -----Chose-----TelephoneEmail Patient details -----Sex-----FemaleMale Product details Time/duration of the incident from: to: Still occurs -----Have the side effects subsided after the usage was discontinued?-----YesNo -----How long the product was used-----OnceRepeatedly Your personal data will be processed in accordance with the Regulation of the European Parliament and of the Council (EU) 2016/679 of 27 April 2016 on the protection of natural persons in regard to the processing of personal data and on the free movement of such data, and repealing Directive 95/46 /EC, General Data Protection Regulation. The Administrator of your personal data is Farmina sp. z o.o., ul. Lipska 44, 30-721 Kraków, Poland, e-mail: info@farmina.pl. Your personal data will be processed solely to report medical incident. Your personal data will not be transferred to third parties. You have the right to access personal data, the right to request correction (revision) of personal data - if the data is incorrect or incomplete or the right to request the deletion of personal data. The provision of personal data by you is voluntary.