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..

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

DESCRIPTION OF THE ADVERSE EFFECT
How severe was the adverse effect? (Please tick the appropriate box to specify how severe the drug's adverse effect was)
MildUnpleasant - allowing for daily activitySevere - hindering daily activitySevere - medical consultation neededHospital treatment requiredSerious medical conditionResulting in death
How do you evaluate your present health condition? (Please tick the appropriate box)
Good (the symptoms have subsided)ImprovementThe symptoms continueDeterioration
DESCRIPTION OF THE ADVERSE EFFECT
Data of the person who experienced the adverse event (Please provide as much information as possible Sex:
FemaleMale
DRUGS WHICH COULD HAVE CAUSED THE ADVERSE EFFECTS

Please provide details about the which could have caused the adverse effect.

Drug used (1)
(1) Prescription drug?
YesNo (1) Was the use of the drug discontinued due to the adverse effect? YesNo
Drug used (2)
(2) Prescription drug?
YesNo (2) Was the use of the drug discontinued due to the adverse effect?
YesNo
ATTENDING PHYSICIAN
Would you like this report to be sent to your attending physician?
YesNo

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

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.