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?*

YesNo

Period of use of the medicine

Renal disease*

YesNo

Liver disease *

YesNo

Pregnancy*

YesNo

Information about concomitant medicines

Additional information about the healthcare institution and the attending physician

Reported by

I agree to processing my personal data and / or transfer it to third parties for the purposes related to its completion *