Adverse Event Reporting Form

It takes 3 minutes to complete the form on average

This survey helps us understand any possible adverse events, and to set appropriate medical guidelines for the general public.

Consent to disclose medical information

I give my consent and permission for the Ministry of Health to use my personal contact information provided to my HMO health insurance in order to:

- Verify my identity with the information that I have entered in this website.

- Send a one-time passcode.

- Give this website access to my vaccination and recovery records and results of my past or future coronavirus tests.

I acknowledge that to verify my identity, the details that I enter in this website must be identical to the identification details that I provided to my HMO health insurance.

I agree that the identification details entered will also be used for my children whose HMO verification relies on my phone number.

Accept Please accept the terms

Personal information

Fields marked with an asterisk are required *

A new questionnaire must be completed for each person. After you submit this survey you will be able to complete another one

I.D.

Passport

I. D. number *

Passport number *

Mobile Phone Number: *

Last name *

First name *

Date of birth *

Day

Enter day of birth (DD)

Month

Enter month of birth (MM)

Year

Enter year of birth (YYYY) Enter year of birth (YYYY) Enter year of birth (YYYY)

Incorrect number entered

Verify the phone number you entered

Enter the passcode that has been sent to {0}

Enter 1 verification code Enter 2 verification code Enter 3 verification code Enter 4 verification code Enter 5 verification code Enter 6 verification code

We could not find your vaccination details

Please make sure all the personal details you have entered are correct. If everything is OK - contact your HMO and update the ID card, telephone number and date of birth you filled out in the form

More Info

Let's try again

Why do we ask you for your personal details?

The details are necessary for identity verification

Please consult a doctor

At least one of the symptoms you've shared with us is considered a serious side effect. This survey is not a substitute for consulting your doctor if necessary.

I see, thank you.

Oops, something went wrong

The details cannot be verified at the moment

Try again

I will try again later