Drug safety

Form for submitting initial information on adverse drug reaction

Use the form below.
All fields marked with asterix (*) must be completed.



PATIENT *

It is mandatory to fill one of the folloing fields

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ADVERSE DRUG REACTION (ADR)

Outcome of adverse drug reaction

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(if you think it is important)

SUSPECTED DRUG PRODUCT

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(name, daily dose, indications)

INTAKE OF OTHER NON-SUSPECT DRUG PRODUCTS:

(name, daily dose, indications )

DATA ON SUBMITTING PERSON

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