Report of adverse events

Name
Surname
E-mail*
Country*
Professional qualification*
Report of adverse events
Age and gender of the person who experienced adverse event*
Male
Female
Description of adverse events and date of their occurrence*
Medicinal products which you suspect to have caused the adverse event* (product name, pharmaceutical form and strength, dosage and way of use, starting date of therapy)
Batch number
Have you consulted your doctor or pharmacist about the adverse event? Have you stopped taking your medicine? Has the adverse event abated and when?*
Condition for which you are/have been taking this medicine*
Please list all other medicines you have been taking in the last week before the occurrence of the adverse event, including herbal products, vitamins, contraceptive agents, etc.*
Please state possible allergies or chronic health conditions*
If you are a woman, are you pregnant or breastfeeding?
Any questions?
We wish to inform you that you will share personal data when reporting adverse reaction to KRKA SUBSIDIARY, which we have to process and permanently store according to legislation governing medicinal products. We will use your data only for monitoring, analysis and reporting relating to the safety of the product. You are invited to read more about presonal data protection here.