Fill in the adverse reaction report form

In case you (as a patient) or one of your patients (as a doctor or pharmacist) suspect an adverse reaction to one of our medicines, please fill in the adverse reaction reporting form below.

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Adverse reaction reporting form

1. Patient

Initials
Date of birth *
Sex *
Height (cm)
Weight (kg)

2. Product involved

Product name (prescription or OTC) and indication *

3. Adverse reaction

Description of adverse reaction *

4. Date of occurrence of the adverse reaction and circumstances

Date of issue *
Circumstances *

5. Product details

Start date of treatment/use
Date of possible interruption of treatment/use
Pharmaceutical form and dose/day
Series / lot

6. Action taken in relation to the adverse reaction

Stopping treatmentDose reductionOther
Other actions (if any)

7. Concomitant treatment

Concomitant treatment (name, dose, dates)

8. Date of cessation of the adverse reaction

Date of termination

9. Concomitant associated pathology

Pathology details

10. Rapporteur

ConsumerSupporterHealth professional
Name *
Address
Telephone *

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I have read and agree with Terms and conditions of use.

Information marked with * is mandatory.