Report adverse events

Step 1: Details of the reporting person

First name* Last name* Education, specialization Place of practice Street Zip code City Phone* Email address* Date

Step 2: Patient data

Initials* Gender* WomanMan E-mail address Date of birth* Age Weight

Step 3: Side effects

Description of side effects* Date of onset of symptoms* Classification - severe side effects threat to lifepermanent or substantial disability or incapacityhospitalisation or prolongation of hospitalisationother which the doctor to the best of his knowledge considers to be seriousdeath

No. statistical cause of death

PregnancyTakNo

Pregnancy week

Treatment outpatienthospital Result recovery without permanent consequencesrecovery with permanent consequencesis undergoing treatment for symptomsunknown

Step 4: The drug used

Drug Name of the drug Start date of the study Application route Date of completion of the study Dosage Cause of use or statistical number of the disease Drug suspected of causing symptoms YesNo

Step 5: Additional information (e.g., previous reactions to the drug, risk factors, results of additional tests) Adverse effect of a medicinal product - this is any adverse and unintended effect of a medicinal product The administrator of your personal data is Przedsiębiorstwo Produkcji Farmaceutycznej HASCO-LEK S.A. with its registered office in Wrocław, at ul. Żmigrodzka 242e. Your personal data will be processed for the purpose of reporting and handling a medical incident. A full range of information on data protection, including a listing of your rights, is available at https://www.hasco-lek.pl/polityka-prywatnosci/

Suspect adverse reaction report form

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Medical incident form

Report adverse events

Headquarters