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Reporter contact information/Initials*

Reporter Phone*

Reporter e-mail address*

Province*

Product/Drug name*

Dosage/Route/Frequency

Therapy Start date

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Reason for use of B+L product*

Patient Initials*

Date of birth

Height/Weight of Patient

Please describe the Adverse reaction/Side effect/Product complaint*

Please describe Concomitant Medication (Include medications taken within 30 days before Adverse Reaction onset. Do not include medications taken as a treatment for the Adverse Reaction)

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