Form for reporting an dverse drug reaction, caused by treatment with medicine produced by Adipharm.

Messages can be send by all medicine specialists: doctors, dentist and etc. Patients that believe they have experienced Adverse Drug Reactions should contact their doctor.

Do not give up to send us message even if some part of information is missing..

Adverse Drug Reaction messages should be reported in 24h after their happening:

т: +359 860 20 00
e: complaint@adipharm.com

Qualified Person, 0-24h

Aneliya Ganeva
т: +359 882 839 881

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1 Step 1
Patient
Age
Sex

Adverse Drug Reaction (ADR)
0 /
Duration From
date_range
To
date_range

Suspected Medicine
Daily Dose
Applying Method

Duration of use

From
date_range
To
date_range
Indications
date_range
date_range

Other Medicines
Daily Dose
Applying Method

Duration of use

From
date_range
To
date_range
Indications
date_range
date_range

Other Medicines
ADR cause:
Exit from ADR:
Does the ill person have been used the medicine before?
date_range

Comment(concomitant diseases, allergies, tests)
0 /

Relation between suspected medicine and ADRAdditional information (If the fields are not enough)
0 /

First Name
Last Name
Occupation
Address
Phone
phone
Date
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