Report form

For submission by patient and/or his/her representative of information on adverse reaction and/or lack of efficacy of a medicinal product

1. Information On Patient

   Patient’s full name: Date of birth: Gender: malefemale Address: Tel: Email:

2. Information on suspected medicinal product

   Trade name: Pharmaceutical form: Manufacturer:

3. Information on prescription of suspected medicinal product

   The suspected medicinal product was prescribed to the patient by a physician? YesNo The patient used the suspected medicinal product without a physician’s prescription? YesNo Description of manifestations of adverse reaction of a medicinal product and/or indication of the lack of efficacy of a medicinal product:

4. Information on reporter

   Reporter’s full name: Tel: Email: Address:

5. Information on physician and healthcare facility

   Physician’s name: Name of healthcare facility where the physician is employed: Address of healthcare facility where the physician is employed: Tel. of healthcare facility where the physician is employed: E-mail of healthcare facility where the physician is employed: