e-form

Advertised Medicinal Product Complaint Form

All relevant fields must be filled in before the form can be accepted and your complaint investigated.

1. Complainant details:





Name:





Surname:





Title:





Address:





Telephone No:





E-mail address:





Signature of complainant: (if you use online submission, please use the Declaration Form)

Kindly fill in the Declaration form at the following link http://www.medicinesauthority.gov.mt/onlineapplications
A Declaration form should be submitted for each signatory.





2. Advertisement details:

Name of medicinal product advertised:







Name of company/ advertiser:





Address of advertiser (if known):





Media in which advertisement appeared:





Other:





AV004/04 Appendix 1 Version 1

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