For healthcare professionals

Report a drug's adverse effect.

Note: 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 fax to 698 744 600
  • or with the form presented below

Fields marked with a red asterisk (*) are mandatory.

* indicates required field


PATIENT DATA




DESCRIPTION OF ADVERSE EFFECTS


Classification










STOSOWANE LEKI
Proszę o podanie wszystkich produktów leczniczych stosowanych przez pacjenta, nawet jeśli ich stosowanie w Pani/Pana ocenie nie ma związku z wystąpieniem działania niepożądanego.


Drug used (1)

Drug used (2)

Drug used (3)

Drug used (4)






ADDITIONAL INFORMATION


DATA OF THE PERSON REPORTING THE ADVERSE EFFECT






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.