PHARMACOVIGILANCE FEEDBACK FORM FOR SPECIALISTS

For a medical or pharmaceutical specialist

*fields with an asterisk are mandatory

1. Medical or pharmaceutical specialist reporting an ADR

Second name, first name, patronymic (if any)^*

Phone^*

Job and name of employer^*

Address of institution^*

Country^*

4. Important additional information

Clinical, laboratory, radiological, and autopsy findings, including drug concentrations in blood (tissue), if any and if associated with the adverse reaction (please provide dates)

Concomitant diseases, anamnestic data

Suspected drug interactions

For congenital abnormalities, list all other drugs taken during pregnancy, as well as the date of the last menstruation

Attach files

Maximum number of files - 10.Maximum file size - 10Mb.Acceptable extensions:(*.jpg,*.gif,*.png,*.doc,*.docx,*.xls,*.xlsx,*.pdf)

5. Information regarding the company’s privacy policy

Consent to the collection, processing, storage and use of personal data^*

Consent to the company’s privacy policy^*