Medicinal products for human use

Patient information

Information on the person who reported the adverse reaction

Have you consulted a doctor, pharmacist or other healthcare professional about the adverse reaction, or has the patient done so?

yes

no

On whose behalf are you reporting this adverse reaction?

for myself

for someone else

Information on the person who experienced the adverse reaction

Gender

male

female

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Medicinal product

Information on the medicinal product that caused the adverse reaction

This image shows where you can locate the batch number:

I can’t find the batch number

Has the patient stopped taking the medicine?

yes

no

Had the patient been taking any other medicine before the adverse reaction occurred?

yes

no

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Adverse reaction

Description of the adverse reaction and related information

If you wish you can even upload an image or a file with the description of the adverse reaction.

Remove file

Has the patient received a medicine for treating the adverse reaction?

yes

no

Additional and legal information

May we contact you if we require additional information?

yes

no

We would like to inform you that by reporting the adverse reaction you will be sending your personal information to Krka, d. d., Novo mesto, Slovenia. Krka is required to process and store such information in line with legislation on medicines. Your data will only be used for monitoring, analysing and reporting about product safety. Please find more details about personal data protection here.

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Medicinal products for human use

Patient information

Medicinal product

Adverse reaction

Report on adverse reaction