Notification card to fill in

Please use the form below to report any ineffectiveness or side effects of a medicine:


Fields marked with * are required to be filled

    Patient information

    Information about the suspected medicine

    Information about an adverse drug reaction

    Was this medicine prescribed by a doctor?*

    Period of use of the medicine

    Renal disease*

    Liver disease *


    Information about concomitant medicines

    Additional information about the healthcare institution and the attending physician

    Reported by