Adverse drug reactions – Kéri Pharma Hungary

Reporting adverse drug reactions

Please fill out the form carefully, an incomplete form may affect the professional evaluation of the case.

Name of the reporter

E-mail address of the reporter

Phone number of the reporter

Is the reporter a healthcare worker?

Yes No

Age of the patient

Gender of the patient

Female Male

The dose of the medicine causing the complaint

When did the patient start to use the medicine causing the complaint?

Did the patient discontinue the use of the medicine causing the complaint?

Yes No

When did the patient discontinue to use the medicine causing the complaint?

What was the exact name of the product?

What adverse drug reaction does the patient experience? (Please describe in a few words.)

What is the name of the disease for which the medicine has been used?

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