Report adverse events

Suspect adverse reaction report

Sender

Patient info

Describe adverse reaction(s)


Result

Concomitant drug(s) and history

    Additional Information

    including previous drug(s) reaction(s), risk factors, relevant tests/lab date

    I hereby authorize PPF Hasco-Lek S.A. situated in Wrocław 51-131 at Żmigrodzka 242E, to process my personal data included in this form in order to process a report concerning an adverse effect of a medicine.

    PPF Hasco-Lek S.A. situated in Wrocław 51-131 at Żmigrodzka 242 has the right to manage this data. Personal data provided in this form is intended to supplement the report concerning an adverse effect of a medicine. You have the right to access and modify provided information. The information is provided voluntarily and its scope is defined by the law (European Comission Implementing Regulation 520/2012 from June 19th 2012; Official Journal of the European Union L159 from June 20th 2012r.).

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