Formulaire

Patient reporting of adverse drug or health product events via a patient form (Form 15031*04)

Cerfa 15031*04

Helps to report any side effects you may have noticed after taking a medicine.

    Fill out the form

    To whom shall I send this form ?

    J'ai réalisé une démarche administrative

    Je donne mon avis sur Services Publics +. L'administration concernée me répondra.

    Je donne mon avis

    Émetteur du formulaire administratif : Ministry of Health

    Verified 01 April 2021 - Directorate for Legal and Administrative Information (Prime Minister)