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

    Gender:
  2. Information on suspected medicinal product

  3. Information on prescription of suspected medicinal product

    The suspected medicinal product was prescribed to the patient by a physician? The patient used the suspected medicinal product without a physician’s prescription?
  4. Information on reporter

  5. Information on physician and healthcare facility