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