Patient Adverse Event Reporting Card

regarding an adverse reaction and/or lack of efficacy of a medicinal product during clinical use.
*- required field

1. PATIENT INFORMATION

Patient's full name: *

DOB:

Sex:

MaleFemale

Address:

Phone: *

Email: *

2. SUSPECTED DRUG INFORMATION

Trade name: *

Batch number:

3. INFORMATION ON THE INDICATION OF THE SUSPECTED DRUG

Was the suspected drug prescribed to the patient by a doctor?

YesNo

Did the patient use the suspected drug without a doctor's prescription?

YesNo

Description of adverse drug reaction and/or indication of lack of efficacy: *

4. REPORTER INFORMATION

Reporter's full name: *

Phone/факс: *

Email: *

Address:

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