Contact form for Specialists

Medicine being reported:

Other medicines used:

Reporting person data:

Patient data:

Patient initials:
Sex
Age
Adverse drug reactions (describe briefly):
Duration of adverse drug reaction (ADR) From:

to:

Trade name
Content form
Batch number
Method of administration
Dosage and frequency of administration
Duration of administration From:

to:

Indications
Trade name 1:
Content form
Method of administration
Duration of administration From:

to:

Indications
Trade name 2:
Content form
Method of administration
Duration of administration From:

to:

Indications
Trade name 3:
Content form
Method of administration
Duration of administration From:

to:

Indications
The medicine being reported was:
Has the patient used the medicine before:
ADR has led to:
ADR outcome:
Comments (patient history data, allergies, ADR treatment)
Connection between the medicine being reported and the adverse reaction:
Additional information that could not be fitted into the boxes provided
Name:
Specialty:
Address:
Telephone