For the patient

Report a drug's adverse effect.

This form is intended for patients; if you are a healthcare professional, go to the form which was prepared for your needs.

Note: Celon Pharma is not authorised to provide medical advice, nor to confirm whether the experienced symptoms have been caused by the drug.

Note: Celon Pharma is not authorised to provide medical advice, nor to confirm whether the experienced symptoms have been caused by the drug.

* indicates required field


DESCRIPTION OF THE ADVERSE EFFECT













Data of the person who experienced the adverse event (Please provide as much information as possible)



DRUGS WHICH COULD HAVE CAUSED THE ADVERSE EFFECTS
Please provide details about the which could have caused the adverse effect.

Drug used (1)


Drug used (2)






ATTENDING PHYSICIAN (this part is optional)



If the answer is yes, please provide the full name and address of the physician


INFORMATION ABOUT THE PERSON REPORTING THE ADVERSE EFFECT
Contact details - please provide a full mailing address, phone number, e-mail address



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.