You can inform us of a suspected undesirable reaction in free form, in which case please indicate the following:

    • Your name, surname, profession, company name, address and telephone number;
    • The initials of the patient, his/her age, gender and weight;
    • The product suspected of causing the reaction, dosage, consumption and the duration of its consumption, the illness being treated;
    • Information on the suspected undesirable reaction: duration (dates for the start and end) and outcome (the patient has recovered, is recovering, the URD continues, etc.), whether the URD has been confirmed by a doctor; an evaluation of the link to the drug’s consumption (suspected, possible, likely, certain);
    • Accompanying illnesses;
    • Information on other drugs in use: their dosage, mode of consumption, duration (dates for the start and end), indications.

Please send the completed form:

 

We sincerely thank you for your co-operation.