For healthcare professionals

Report a drug's adverse effect.

Uwaga: this section is addressed to healthcare professionals. If you are a patient/caregiver, go to the form which was prepared for your needs.

    Report an adverse effects:
    • With a yellow card form Yellow card form
      - fill the form in and send it via e-mail: [email protected] or the original of the application to the address
      Celon Pharma S.A.
      Ogrodowa 2A
      05-092 Łomianki / Kiełpin       with the note "Undesirable effects"
    • or by the form below Fields marked with a asterisk (*) are mandatory.
    Patient data
    Sex: FemaleMale
    Description of the symptoms:
    Outpatient treatment:Inpatient treatment:
    classification
    Is it a severe adverse effect?:?* YesNo Outcome: A - recovery without permanent damageB-recovery with permanent damageF - symptoms are being treatedU - unknown
    Severe adverse effect - please select:?* deathlife-threatening eventpermanent or significant disability or impairment of health conditionhospitalisation or extended hospitalisationother, which the doctor deems severe pursuant to his/her medical knowledge
    Drugs used:
    Please provide all the medicinal products used by the patient, even if their use in your assessment is not related to the occurrence of an adverse reaction.
    Drug used (1)
    (1) P - the drug is suspected of causing the symptoms:
    Drug used (2)
    (2) P - the drug is suspected of causing the symptoms:
    Drug used (3)
    (3) P - the drug is suspected of causing the symptoms:
    Drug used (4)
    (4) P - lek jest podejrzewany o spowodowanie objawów

    Has the adverse effect ceased after drug administration was discontinued?YesNoNot known

    Did the adverse effect occurred again after repeated administration of the drug??YesNoNot known
    ADDITIONAL INFORMATION
    DATA OF THE PERSON REPORTING THE ADVERSE EFFECT

    Personal data collected in connection with the report will be processed by Celon Pharma S.A with its registered address at: ul. Ogrodowa 2a in Łomianki, Pursuant to the Act of 29 August 1997 on personal data protection (Journal of Laws of 2002 No. 101 item 926, as amended) solely for the purpose of meeting the obligation consisting in monitoring of safety of medicinal products. Persons reporting adverse effects of medicinal products are obliged to provide their personal data under the Act of 6 September 2001 - Pharmaceutial law (Journal of Laws of 2008, No. 45, item 271, as amended) and other provisions of law. In the case of other persons, providing personal information is voluntary but necessary for the report to be accepted. Everyone has the right to access their his/her data and correct it.