{"id":12372,"date":"2017-11-23T12:48:42","date_gmt":"2017-11-23T12:48:42","guid":{"rendered":"https:\/\/celonpharma.com\/?page_id=12372"},"modified":"2017-11-23T13:45:18","modified_gmt":"2017-11-23T13:45:18","slug":"for-healthcare-professionals","status":"publish","type":"page","link":"https:\/\/celonpharma.com\/en\/for-healthcare-professionals\/","title":{"rendered":"For healthcare professionals"},"content":{"rendered":"<div>\n<p><span class=\"bold\">Report a drug&#8217;s adverse effect.<\/span><\/p>\n<p><span class=\"bold orange-write\">Uwaga: <\/span>this section is addressed to healthcare professionals. If you are a patient\/caregiver, go to <span class=\"bold orange-write\"><a href=\"\/\">the form which was prepared for your needs.<\/a><\/span><\/p>\n<\/div>\n<div>\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f12374-o1\" lang=\"pl-PL\" dir=\"ltr\" data-wpcf7-id=\"12374\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/en\/wp-json\/wp\/v2\/pages\/12372#wpcf7-f12374-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Formularz kontaktowy\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"12374\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.6\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"pl_PL\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f12374-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/><input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/fieldset>\n<div class=\"drug-form-wrapper\">\n<div class=\"drug-form-block block grey form-margin relative\">\n\t<h6 class=\"orange-write bold\">Report an adverse effects:<\/h6>\n\t\t<ul>\n\t\t\t<li>\n\t\t\tWith a yellow card form  <a href=\"#\">Yellow card form<\/a>\n<br\/>- fill the form in and send it via e-mail: dzialania.niepozadane@celonpharma.com\n\t\t\tor the original of the application to the address <span class=\"bold\"><br\/>Celon Pharma S.A.<br\/>\n\t\t\tOgrodowa 2A<br\/>\n\t\t\t05-092 \u0141omianki \/ Kie\u0142pin<\/span>\n\t\t\twith the note \"Undesirable effects\"\n\t\t\t<\/li>\n\t\t\t<li>\n\t\tor by the form below Fields marked with a asterisk (<span class=\"orange-write\">*<\/span>) are mandatory.\n\t\t<\/li>\n\t\t<\/ul>\n<\/div>\n<div class=\"grey drug-form-block form-margin\">\n\t<h6 class=\"bold orange-write uppercase\">Patient data<\/h6>\n\t<div class=\"grid-x grid-margin-x\">\n\t\t<div class=\"large-4 cell\">\n\t\t\t<label> Initials: <span class=\"bold orange-write\">*<\/span>\n\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"employee-patient-initials\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"employee-patient-initials\" \/><\/span>\n\t\t\t<\/label>\n\t\t<\/div>\n\t\t<div class=\"large-3 cell\">\n\t\t\t<label> Date of birth\/age: <span class=\"bold orange-write\">*<\/span>\n\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"employee-patient-birthday\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"employee-patient-birthday\" \/><\/span>\n\t\t\t<\/label>\n\t\t<\/div>\n\n\t\t<div class=\"large-3 cell\">\n\t\t\t Sex:\n\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"radio-gender-employee-patient\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-gender-employee-patient\" value=\"Female\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Female<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-gender-employee-patient\" value=\"Male\" \/><span class=\"wpcf7-list-item-label\">Male<\/span><\/span><\/span><\/span>\n\t\t\t\n\t\t<\/div>\n\n\t\t<div class=\"large-2 cell\">\n\t\t\t<label> Body weight:<span class=\"bold orange-write\">*<\/span>\n\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"employee-patient-weight\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"employee-patient-weight\" \/><\/span>\n\t\t\t<\/label>\n\t\t<\/div>\n\t<\/div>\n\t<h6 class=\"bold orange-write uppercase\">Description of the symptoms:<\/h6>\n\t<div class=\"grid-x grid-margin-x\">\n\t\t<div class=\"large-6 cell\">\n\t\t\t  <label> Symptom onset date:<span class=\"bold orange-write\">*<\/span>\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"employee-undesirable-symptoms\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"employee-undesirable-symptoms\" \/><\/span> <\/label>\n\t\t\t  <label> If the patient is pregnant, please indicate the week of pregnancy:<span class=\"bold orange-write\">*<\/span>\n\t\t\t <span class=\"wpcf7-form-control-wrap\" data-name=\"employee-trymestr\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"employee-trymestr\" \/><\/span> <\/label>\n\t\t\t\n\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-employee-treatment\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"checkbox-employee-treatment[]\" value=\"Outpatient treatment:\" \/><span class=\"wpcf7-list-item-label\">Outpatient treatment:<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"checkbox-employee-treatment[]\" value=\"Inpatient treatment:\" \/><span class=\"wpcf7-list-item-label\">Inpatient treatment:<\/span><\/span><\/span><\/span>\n\t\t\t\n\t\t <\/div>\n\t   <div class=\"large-6 cell\">\n\t\t\t<label> Description of the symptoms<span class=\"bold orange-write\">*<\/span>\n\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"employee-symptoms\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"employee-symptoms\"><\/textarea><\/span>\n\t\t\t<\/label>\n\t   <\/div>\n\t<\/div>\n\n\t<h6 class=\"bold orange-write uppercase\">classification<\/h6>\n\t<div class=\"grid-x grid-margin-x\">\n\t\t<div class=\"large-6 cell\">\n\t\t\tIs it a severe adverse effect?:?<span class=\"bold orange-write\">*<\/span>\n\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"employee-severe-efect\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"employee-severe-efect\" value=\"Yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"employee-severe-efect\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\n\t\t\t<label> Statistical number of the cause of death: <span class=\"bold orange-write\">*<\/span>\n\t\t\t    <span class=\"wpcf7-form-control-wrap\" data-name=\"cause-deth\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"cause-deth\" \/><\/span> <\/label>\n\t\t\tOutcome:\n\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"treatment-outcome\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"treatment-outcome\" value=\"A - recovery without permanent damage\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">A - recovery without permanent damage<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"treatment-outcome\" value=\"B-recovery with permanent damage\" \/><span class=\"wpcf7-list-item-label\">B-recovery with permanent damage<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"treatment-outcome\" value=\"F - symptoms are being treated\" \/><span class=\"wpcf7-list-item-label\">F - symptoms are being treated<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"treatment-outcome\" value=\"U - unknown\" \/><span class=\"wpcf7-list-item-label\">U - unknown<\/span><\/span><\/span><\/span>\n\t\t\t\n\t\t<\/div>\n\t\t<div class=\"large-6 cell\">\n\t\t\tSevere adverse effect - please select:?<span class=\"bold orange-write\">*<\/span>\n\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"side-efect-examples\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"side-efect-examples\" value=\"death\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">death<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"side-efect-examples\" value=\"life-threatening event\" \/><span class=\"wpcf7-list-item-label\">life-threatening event<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"side-efect-examples\" value=\"permanent or significant disability or impairment of health condition\" \/><span class=\"wpcf7-list-item-label\">permanent or significant disability or impairment of health condition<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"side-efect-examples\" value=\"hospitalisation or extended hospitalisation\" \/><span class=\"wpcf7-list-item-label\">hospitalisation or extended hospitalisation<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"side-efect-examples\" value=\"other, which the doctor deems severe pursuant to his\/her medical knowledge\" \/><span class=\"wpcf7-list-item-label\">other, which the doctor deems severe pursuant to his\/her medical knowledge<\/span><\/span><\/span><\/span>\n\t\t\t\n\t\t<\/div>\n\t<\/div>\n<\/div>\n\n<div class=\"drug-form-block grey form-margin\">\n   <h6 class=\"orange-write bold uppercase\">Drugs used:<\/h6>\n   <span class=\"drug-info\">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.<\/span>\n\t<div class=\"grid-x drug-form grid-padding-x\">\n\t\t<div class=\"large-3 cell drug-form-cell\">\n\t\t\t<h6 class=\"orange-write\">Drug used (1)<\/h6>\n\t\t\t<label> (1) Name of the drug:<span class=\"bold orange-write\">*<\/span>\n\t\t\t    <span class=\"wpcf7-form-control-wrap\" data-name=\"drug-name-1\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"drug-name-1\" \/><\/span>\n\t\t\t<\/label>\n\t\t\t\n\t\t\t     <span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-guilty-symptoms-1\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"checkbox-guilty-symptoms-1[]\" value=\"(1) P - the drug is suspected of causing the symptoms:\" \/><span class=\"wpcf7-list-item-label\">(1) P - the drug is suspected of causing the symptoms:<\/span><\/span><\/span><\/span>\n\t\t\t\n\t\t\t<label>(1) Daily dosage:<span class=\"bold orange-write\">*<\/span>\n\t\t\t    <span class=\"wpcf7-form-control-wrap\" data-name=\"employee-daily-dose-1\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"employee-daily-dose-1\" \/><\/span>\n\t\t\t<\/label>\n\t\t\t<label>(1) Route of administration:<span class=\"bold orange-write\">*<\/span>\n\t\t\t    <span class=\"wpcf7-form-control-wrap\" data-name=\"employee-method-drug-1\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"employee-method-drug-1\" \/><\/span>\n\t\t\t<\/label>\n\t\t\t<label>(1) Date on which administration was commenced:<span class=\"bold orange-write\">*<\/span>\n\t\t\t    <span class=\"wpcf7-form-control-wrap\" data-name=\"employee-start-date-drug-1\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"employee-start-date-drug-1\" \/><\/span>\n\t\t\t<\/label>\n\t\t\t<label>(1) Date on which administration was discontinued:<span class=\"bold orange-write\">*<\/span>\n\t\t\t    <span class=\"wpcf7-form-control-wrap\" data-name=\"employee-end-date-drug-1\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"employee-end-date-drug-1\" \/><\/span>\n\t\t\t<\/label>\n\t\t\t<label>(1) Reason for use or statistical number of the disease:<span class=\"bold orange-write\">*<\/span>\n\t\t\t    <span class=\"wpcf7-form-control-wrap\" data-name=\"employee-causse-illnes-1\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"employee-causse-illnes-1\" \/><\/span>\n\t\t\t<\/label>\n\t\t<\/div>\n\t\t<div class=\"large-3 cell drug-form-cell\">\n\t\t\t<h6 class=\"orange-write\">Drug used (2)<\/h6>\n\t\t\t<label>(2) Name of the drug:<span class=\"bold orange-write\">*<\/span>\n\t\t\t    <span class=\"wpcf7-form-control-wrap\" data-name=\"employee-drug-name-2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"employee-drug-name-2\" \/><\/span>\n\t\t\t<\/label>\n\t\t\t\n\t\t\t   <span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-guilty-symptoms-2\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"checkbox-guilty-symptoms-2[]\" value=\"(2) P - the drug is suspected of causing the symptoms:\" \/><span class=\"wpcf7-list-item-label\">(2) P - the drug is suspected of causing the symptoms:<\/span><\/span><\/span><\/span>\n\t\t\t\n\t\t\t<label>(2) Daily dosage:<span class=\"bold orange-write\">*<\/span>\n\t\t\t    <span class=\"wpcf7-form-control-wrap\" data-name=\"employee-daily-dose-2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"employee-daily-dose-2\" \/><\/span>\n\t\t\t<\/label>\n\t\t\t<label>(2) Route of administration:<span class=\"bold orange-write\">*<\/span>\n\t\t\t    <span class=\"wpcf7-form-control-wrap\" data-name=\"employee-method-drug-2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"employee-method-drug-2\" \/><\/span>\n\t\t\t<\/label>\n\t\t\t<label>(2) Date on which administration was commenced:<span class=\"bold orange-write\">*<\/span>\n\t\t\t    <span class=\"wpcf7-form-control-wrap\" data-name=\"employee-start-date-drug-2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"employee-start-date-drug-2\" \/><\/span>\n\t\t\t<\/label>\n\t\t\t<label>(2) Date on which administration was discontinued:<span class=\"bold orange-write\">*<\/span>\n\t\t\t    <span class=\"wpcf7-form-control-wrap\" data-name=\"employee-end-date-drug-2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"employee-end-date-drug-2\" \/><\/span>\n\t\t\t<\/label>\n\t\t\t<label>(2) Reason for use or statistical number of the disease:<span class=\"bold orange-write\">*<\/span>\n\t\t\t    <span class=\"wpcf7-form-control-wrap\" data-name=\"employee-causse-illnes-2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"employee-causse-illnes-2\" \/><\/span>\n\t\t\t<\/label>\n\t\t<\/div>\n\t\t<div class=\"large-3 cell drug-form-cell\">\n\t\t\t<h6 class=\"orange-write\">Drug used (3)<\/h6>\n\t\t\t<label>(3) Name of the drug:<span class=\"bold orange-write\">*<\/span>\n\t\t\t    <span class=\"wpcf7-form-control-wrap\" data-name=\"employee-drug-name-3\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"employee-drug-name-3\" \/><\/span>\n\t\t\t<\/label>\n\t\t\t\n\t\t\t     <span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-guilty-symptoms-3\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"checkbox-guilty-symptoms-3[]\" value=\"(3) P - the drug is suspected of causing the symptoms:\" \/><span class=\"wpcf7-list-item-label\">(3) P - the drug is suspected of causing the symptoms:<\/span><\/span><\/span><\/span>\n\t\t\t\n\t\t\t<label>(3) Daily dosage:<span class=\"bold orange-write\">*<\/span>\n\t\t\t    <span class=\"wpcf7-form-control-wrap\" data-name=\"employee-daily-dose-3\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"employee-daily-dose-3\" \/><\/span>\n\t\t\t<\/label>\n\t\t\t<label>(3) Route of administration:<span class=\"bold orange-write\">*<\/span>\n\t\t\t    <span class=\"wpcf7-form-control-wrap\" data-name=\"employee-method-drug-3\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"employee-method-drug-3\" \/><\/span>\n\t\t\t<\/label>\n\t\t\t<label>(3) Date on which administration was commenced:<span class=\"bold orange-write\">*<\/span>\n\t\t\t    <span class=\"wpcf7-form-control-wrap\" data-name=\"employee-start-date-drug-3\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"employee-start-date-drug-3\" \/><\/span>\n\t\t\t<\/label>\n\t\t\t<label>(3) Date on which administration was discontinued:<span class=\"bold orange-write\">*<\/span>\n\t\t\t    <span class=\"wpcf7-form-control-wrap\" data-name=\"employee-end-date-drug-3\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"employee-end-date-drug-3\" \/><\/span>\n\t\t\t<\/label>\n\t\t\t<label>(3) Reason for use or statistical number of the disease:<span class=\"bold orange-write\">*<\/span>\n\t\t\t    <span class=\"wpcf7-form-control-wrap\" data-name=\"employee-causse-illnes-3\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"employee-causse-illnes-3\" \/><\/span>\n\t\t\t<\/label>\n\t\t<\/div>\n\t\t<div class=\"large-3 cell drug-form-cell-4\">\n\t\t\t<h6 class=\"orange-write\">Drug used (4)<\/h6>\n\t\t\t<label>(4) Name of the drug:<span class=\"bold orange-write\">*<\/span>\n\t\t\t    <span class=\"wpcf7-form-control-wrap\" data-name=\"employee-drug-name-4\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"employee-drug-name-4\" \/><\/span>\n\t\t\t<\/label>\n\t\t\t\n\t\t\t     <span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-guilty-symptoms-4\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"checkbox-guilty-symptoms-4[]\" value=\"(4) P - lek jest podejrzewany o spowodowanie objaw\u00f3w\" \/><span class=\"wpcf7-list-item-label\">(4) P - lek jest podejrzewany o spowodowanie objaw\u00f3w<\/span><\/span><\/span><\/span>\n\t\t\t\n\t\t\t<label> (4) Daily dosage:<span class=\"bold orange-write\">*<\/span>\n\t\t\t    <span class=\"wpcf7-form-control-wrap\" data-name=\"employee-daily-dose-4\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"employee-daily-dose-4\" \/><\/span>\n\t\t\t<\/label>\n\t\t\t<label> (4) Route of administration:<span class=\"bold orange-write\">*<\/span>\n\t\t\t    <span class=\"wpcf7-form-control-wrap\" data-name=\"employee-method-drug-4\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"employee-method-drug-4\" \/><\/span>\n\t\t\t<\/label>\n\t\t\t<label> (4) Date on which administration was commenced:<span class=\"bold orange-write\">*<\/span>\n\t\t\t    <span class=\"wpcf7-form-control-wrap\" data-name=\"employee-start-date-drug-4\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"employee-start-date-drug-4\" \/><\/span>\n\t\t\t<\/label>\n\t\t\t<label> (4) Date on which administration was discontinued:<span class=\"bold orange-write\">*<\/span>\n\t\t\t    <span class=\"wpcf7-form-control-wrap\" data-name=\"employee-end-date-drug-4\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"employee-end-date-drug-4\" \/><\/span>\n\t\t\t<\/label>\n\t\t\t<label>(4) Reason for use or statistical number of the disease:<span class=\"bold orange-write\">*<\/span>\n\t\t\t    <span class=\"wpcf7-form-control-wrap\" data-name=\"employee-causse-illnes-4\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"employee-causse-illnes-4\" \/><\/span>\n\t\t\t<\/label>\n\t\t<\/div>\n\t<\/div>\n\n\t<div class=\"grid-x grid-margin-x\">\n\t\t<div class=\"large-3 cell\">\n<br\/>\n\t\t\t\n\t\t\tHas the adverse effect ceased after drug administration was discontinued?<span class=\"wpcf7-form-control-wrap\" data-name=\"employee-finish-efect\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"employee-finish-efect\" value=\"Yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"employee-finish-efect\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"employee-finish-efect\" value=\"Not known\" \/><span class=\"wpcf7-list-item-label\">Not known<\/span><\/span><\/span><\/span>\n\t\t\t\n\t\t<\/div>\n\t\t<div class=\"large-3 cell\">\n<br\/>\n\t\t\t\n\t\t\tDid the adverse effect occurred again after repeated administration of the drug??<span class=\"wpcf7-form-control-wrap\" data-name=\"employee-return-efect\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"employee-return-efect\" value=\"Yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"employee-return-efect\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"employee-return-efect\" value=\"Not known\" \/><span class=\"wpcf7-list-item-label\">Not known<\/span><\/span><\/span><\/span>\n\t\t\t\n\t\t<\/div>\n\t\t<div class=\"large-6 cell\">\n\t\t\t<h6 class=\"uppercase\">ADDITIONAL INFORMATION<\/h6>\n\t\t\t<label> e.g. previous reactions to the drug, risk factors, additional test results\n\t\t\t    <span class=\"wpcf7-form-control-wrap\" data-name=\"employee-add-info-efect\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"employee-add-info-efect\"><\/textarea><\/span>\n\t\t\t<\/label>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"grey drug-form-block\">\n\t<h6 class=\"orange-write bold uppercase \">DATA OF THE PERSON REPORTING THE ADVERSE EFFECT<\/h6>\n\t<div class=\"grid-x grid-margin-x\">\n\t\t<div class=\"large-8 cell\">\n\t\t\t<label> Name and surname:<span class=\"bold orange-write\">*<\/span>\n\t\t\t    <span class=\"wpcf7-form-control-wrap\" data-name=\"employe-name-doctor\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"employe-name-doctor\" \/><\/span>\n\t\t\t<\/label>\n\t\t<\/div>\n\t\t<div class=\"large-4 cell\">\n\t\t\t<label>Medical specialisation:<span class=\"orange-write\">*<\/span>\n\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"specialization\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"specialization\" \/><\/span>\n\t\t\t<\/label>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"grid-x grid-margin-x\">\n\t\t<div class=\"cell\">\n\t\t\t<label>Address:<span class=\"orange-write\">*<\/span>\n\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"employee-doctor-adress\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"employee-doctor-adress\" \/><\/span>\n\t\t\t<\/label>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"grid-x grid-margin-x\">\n\t\t<div class=\"large-6 cell\">\n\t\t\t<label> Email <span class=\"bold orange-write\">*<\/span>\n\t\t\t    <span class=\"wpcf7-form-control-wrap\" data-name=\"employee-doctor-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"employee-doctor-email\" \/><\/span>\n\t\t\t<\/label>\n\t\t<\/div>\n\t\t<div class=\"large-3 cell\">\n\t\t\t<label>Phone:<span class=\"bold orange-write\">*<\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"employee-doctor-phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"employee-doctor-phone\" \/><\/span>\n\t\t\t<\/label>\n\t\t<\/div>\n\t\t<div class=\"large-3 cell\"> \n\t\t\t<label>Fax:<span class=\"bold orange-write\">*<\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"employee-doctor-fax\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"employee-doctor-fax\" \/><\/span><\/label>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n\n<div class=\"postcontent-form\">\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"acceptance-employee\"><span class=\"wpcf7-form-control wpcf7-acceptance\"><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"acceptance-employee\" value=\"1\" class=\"no-margin\" aria-invalid=\"false\" \/><\/span><\/span><\/span>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 \u0141omianki, 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.\n\nPersons 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.\n<\/p>\n<\/div>\n<div class=\"text-right\">\n<input class=\"wpcf7-form-control wpcf7-submit has-spinner button\" type=\"submit\" value=\"Send\" \/>\n<\/div>\n<\/div><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n<\/div>\n","protected":false},"excerpt":{"rendered":"<p>Report a drug&#8217;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.<\/p>\n","protected":false},"author":11,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":""},"class_list":["post-12372","page","type-page","status-publish","hentry"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v28.0 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>For healthcare professionals - Celon Pharma<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/celonpharma.com\/en\/for-healthcare-professionals\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"For healthcare professionals - Celon Pharma\" \/>\n<meta property=\"og:description\" content=\"Report a drug&#8217;s adverse effect. 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