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
*- information is required to be filled in

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: