{"id":12486,"date":"2022-12-27T12:57:49","date_gmt":"2022-12-27T11:57:49","guid":{"rendered":"https:\/\/www.hasco-lek.pl\/report-adverse-events\/"},"modified":"2023-05-08T11:29:03","modified_gmt":"2023-05-08T09:29:03","slug":"report-adverse-events","status":"publish","type":"page","link":"https:\/\/www.hasco-lek.pl\/en\/report-adverse-events\/","title":{"rendered":"Report adverse events"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"12486\" class=\"elementor elementor-12486 elementor-1278\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-a035f1e e-flex e-con-boxed e-con e-parent\" data-id=\"a035f1e\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;jet_parallax_layout_list&quot;:[]}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-2e56202 elementor-widget elementor-widget-breadcrumbs\" data-id=\"2e56202\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"breadcrumbs.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<p id=\"breadcrumbs\"><span><span><a href=\"https:\/\/www.hasco-lek.pl\/en\/\">Strona g\u0142\u00f3wna<\/a><\/span><\/span><\/p>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-824548c e-flex e-con-boxed e-con e-parent\" data-id=\"824548c\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;jet_parallax_layout_list&quot;:[]}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-4e66e19 elementor-widget elementor-widget-heading\" data-id=\"4e66e19\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">Suspect adverse reaction\nreport form<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-050fc0f elementor-widget elementor-widget-spacer\" data-id=\"050fc0f\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-dc5d246 elementor-widget elementor-widget-shortcode\" data-id=\"dc5d246\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\">\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f12765-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"12765\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/en\/wp-json\/wp\/v2\/pages\/12486#wpcf7-f12765-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"12765\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.5\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f12765-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/><input type=\"hidden\" name=\"_uacf7_hidden_conditional_fields\" value=\"\" \/><input type=\"hidden\" name=\"_uacf7_repeaters\" value=\"\" \/><input type=\"hidden\" name=\"_uacf7_options\" value=\"\" \/>\n<\/fieldset>\n<div class=\"uacf7-form-wrapper-container uacf7-form-12765  \">\t\t<div class=\"uacf7-step uacf7-step-12765 step-content\"\n\t\t\tnext-btn-text=\"Next\" prev-btn-text=\"Previous\">\n\t\t\t\n\n<span style=\"font-size:16px;font-weight:600;color:#004F9F;line-height:20.11px;\">Step 1:<\/span><span style=\"font-size:18px;font-weight:400;color:#004F9F;line-height:20.11px;\"> Details of the reporting person<\/span>\n<br><br>\n<label>First name*<\/label> <span class=\"wpcf7-form-control-wrap\" data-name=\"imie\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"imie\" \/><\/span>\n<label>Last name*<\/label> <span class=\"wpcf7-form-control-wrap\" data-name=\"nazwisko\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"nazwisko\" \/><\/span>\n<label>Education, specialization<\/label> <span class=\"wpcf7-form-control-wrap\" data-name=\"wyksztalcenie\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"wyksztalcenie\" \/><\/span>\n<label>Place of practice<\/label> <span class=\"wpcf7-form-control-wrap\" data-name=\"miejsce-zawodu\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"miejsce-zawodu\" \/><\/span>\n<label>Street<\/label> <span class=\"wpcf7-form-control-wrap\" data-name=\"ulica\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ulica\" \/><\/span>\n<label>Zip code<\/label> <span class=\"wpcf7-form-control-wrap\" data-name=\"kod-pocztowy\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"kod-pocztowy\" \/><\/span>\n<label>City<\/label> <span class=\"wpcf7-form-control-wrap\" data-name=\"miasto\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"miasto\" \/><\/span>\n<label>Phone*<\/label> <span class=\"wpcf7-form-control-wrap\" data-name=\"telefon\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"telefon\" \/><\/span>\n<label>Email address*<\/label> <span class=\"wpcf7-form-control-wrap\" data-name=\"email-zglaszajacego\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"email-zglaszajacego\" \/><\/span>\n<label>Date<\/label> <span class=\"wpcf7-form-control-wrap\" data-name=\"data\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"data\" \/><\/span>\n\t\t\t<p class=\"uacf7-buttons\">\n\t\t\t\t<button class=\"uacf7-prev\"\n\t\t\t\t\tdata-form-id=\"12765\">Previous<\/button>\n\t\t\t\t<button class=\"uacf7-next\"\n\t\t\t\t\tdata-form-id=\"12765\">Next<\/button>\n\t\t\t\t<span class=\"wpcf7-spinner uacf7-ajax-loader\"><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t\n\n\t\t<div class=\"uacf7-step uacf7-step-12765 step-content\"\n\t\t\tnext-btn-text=\"Next\" prev-btn-text=\"Previous\">\n\t\t\t\n<span style=\"font-size:16px;font-weight:600;color:#004F9F;line-height:20.11px;\">Step 2:<\/span><span style=\"font-size:18px;font-weight:400;color:#004F9F;line-height:20.11px;\"> Patient data<\/span>\n<br><br>\n<label>Initials*<\/label> <span class=\"wpcf7-form-control-wrap\" data-name=\"inicjaly\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"inicjaly\" \/><\/span>\n<label>Gender*<\/label> <span class=\"wpcf7-form-control-wrap\" data-name=\"plec\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"plec\" value=\"Woman\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Woman<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"plec\" value=\"Man\" \/><span class=\"wpcf7-list-item-label\">Man<\/span><\/span><\/span><\/span>\n<label>E-mail address<\/label> <span class=\"wpcf7-form-control-wrap\" data-name=\"emailpacjenta\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-text wpcf7-validates-as-email\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"emailpacjenta\" \/><\/span>\n<label>Date of birth* <\/label>  <span class=\"wpcf7-form-control-wrap\" data-name=\"dataurodzenia\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"\" value=\"\" type=\"date\" name=\"dataurodzenia\" \/><\/span>\n<label>Age<\/label> <span class=\"wpcf7-form-control-wrap\" data-name=\"wiek\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number\" min=\"0\" max=\"150\" aria-invalid=\"false\" placeholder=\"\" value=\"\" type=\"number\" name=\"wiek\" \/><\/span>\n<label>Weight<\/label> <span class=\"wpcf7-form-control-wrap\" data-name=\"waga\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number\" min=\"0\" max=\"500\" aria-invalid=\"false\" placeholder=\"\" value=\"\" type=\"number\" name=\"waga\" \/><\/span>\n\t\t\t<p class=\"uacf7-buttons\">\n\t\t\t\t<button class=\"uacf7-prev\"\n\t\t\t\t\tdata-form-id=\"12765\">Previous<\/button>\n\t\t\t\t<button class=\"uacf7-next\"\n\t\t\t\t\tdata-form-id=\"12765\">Next<\/button>\n\t\t\t\t<span class=\"wpcf7-spinner uacf7-ajax-loader\"><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t\n\n\t\t<div class=\"uacf7-step uacf7-step-12765 step-content\"\n\t\t\tnext-btn-text=\"Next\" prev-btn-text=\"Previous\">\n\t\t\t\n<span style=\"font-size:16px;font-weight:600;color:#004F9F;line-height:20.11px;\">Step 3:<\/span><span style=\"font-size:18px;font-weight:400;color:#004F9F;line-height:20.11px;\"> Side effects<\/span>\n<br><br>\n<label>Description of side effects*<\/label> <span class=\"wpcf7-form-control-wrap\" data-name=\"objawyniepozadane\"><textarea cols=\"40\" rows=\"10\" maxlength=\"1500\" minlength=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"maximum 1500 characters\" name=\"objawyniepozadane\"><\/textarea><\/span>\n<label>Date of onset of symptoms*<\/label> <span class=\"wpcf7-form-control-wrap\" data-name=\"data-objawy\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"data-objawy\" \/><\/span>\n<label>Classification - severe side effects<\/label> <span class=\"wpcf7-form-control-wrap\" data-name=\"klasyfikacja\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"klasyfikacja[]\" value=\"threat to life\" \/><span class=\"wpcf7-list-item-label\">threat to life<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"klasyfikacja[]\" value=\"permanent or substantial disability or incapacity\" \/><span class=\"wpcf7-list-item-label\">permanent or substantial disability or incapacity<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"klasyfikacja[]\" value=\"hospitalisation or prolongation of hospitalisation\" \/><span class=\"wpcf7-list-item-label\">hospitalisation or prolongation of hospitalisation<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"klasyfikacja[]\" value=\"other which the doctor to the best of his knowledge considers to be serious\" \/><span class=\"wpcf7-list-item-label\">other which the doctor to the best of his knowledge considers to be serious<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"klasyfikacja[]\" value=\"death\" \/><span class=\"wpcf7-list-item-label\">death<\/span><\/span><\/span><\/span>\n<div class=\"uacf7_conditional conditional-zgon\">\n<label>No. statistical cause of death<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"nrzgonu\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"nrzgonu\" \/><\/span>\n<\/div>\n<label>Pregnancy<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"ciaza\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"ciaza\" value=\"Tak\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Tak<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"ciaza\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n<div class=\"uacf7_conditional conditional-ciaza\">\n<label>Pregnancy week<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"tydzien-ciazy\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"tydzien-ciazy\" \/><\/span>\n<\/div>\n<label>Treatment<\/label> <span class=\"wpcf7-form-control-wrap\" data-name=\"leczenie\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"leczenie[]\" value=\"outpatient\" \/><span class=\"wpcf7-list-item-label\">outpatient<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"leczenie[]\" value=\"hospital\" \/><span class=\"wpcf7-list-item-label\">hospital<\/span><\/span><\/span><\/span>\n<label>Result<\/label> <span class=\"wpcf7-form-control-wrap\" data-name=\"wynik\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"wynik[]\" value=\"recovery without permanent consequences\" \/><span class=\"wpcf7-list-item-label\">recovery without permanent consequences<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"wynik[]\" value=\"recovery with permanent consequences\" \/><span class=\"wpcf7-list-item-label\">recovery with permanent consequences<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"wynik[]\" value=\"is undergoing treatment for symptoms\" \/><span class=\"wpcf7-list-item-label\">is undergoing treatment for symptoms<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"wynik[]\" value=\"unknown\" \/><span class=\"wpcf7-list-item-label\">unknown<\/span><\/span><\/span><\/span>\n\t\t\t<p class=\"uacf7-buttons\">\n\t\t\t\t<button class=\"uacf7-prev\"\n\t\t\t\t\tdata-form-id=\"12765\">Previous<\/button>\n\t\t\t\t<button class=\"uacf7-next\"\n\t\t\t\t\tdata-form-id=\"12765\">Next<\/button>\n\t\t\t\t<span class=\"wpcf7-spinner uacf7-ajax-loader\"><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t\n\n\t\t<div class=\"uacf7-step uacf7-step-12765 step-content\"\n\t\t\tnext-btn-text=\"Next\" prev-btn-text=\"Previous\">\n\t\t\t\n<span style=\"font-size:16px;font-weight:600;color:#004F9F;line-height:20.11px;\">Step 4:<\/span><span style=\"font-size:18px;font-weight:400;color:#004F9F;line-height:20.11px;\"> The drug used<\/span>\n<br><br>\n\n<div class=\"uacf7_repeater\" repeat=\"\" uacf7-repeater-id=\"uarepeater-120\"><div class=\"uacf7_repeater_sub_fields\"><div class=\"uacf7_repeater_sub_field\">\n<span class=\"uacf7-repeater-title\">Drug<\/span>\n<label>Name of the drug<\/label> <span class=\"wpcf7-form-control-wrap\" data-name=\"nazwaleku\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"nazwaleku\" \/><\/span> \n<label>Start date of the study<\/label> <span class=\"wpcf7-form-control-wrap\" data-name=\"databadaniastart\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"databadaniastart\" \/><\/span> \n<label>Application route<\/label> <span class=\"wpcf7-form-control-wrap\" data-name=\"drogapodania\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"drogapodania\"><option value=\"wybierz z listy poni\u017cej...\">wybierz z listy poni\u017cej...<\/option><option value=\"orally\">orally<\/option><option value=\"in the oral cavity\">in the oral cavity<\/option><option value=\"intramuscularly\">intramuscularly<\/option><option value=\"intravenously\">intravenously<\/option><option value=\"rectally\">rectally<\/option><option value=\"intranasally\">intranasally<\/option><option value=\"subcutaneously\">subcutaneously<\/option><option value=\"on the skin\">on the skin<\/option><option value=\"transdermally (TTS plasters)\">transdermally (TTS plasters)<\/option><option value=\"on mucous membranes\">on mucous membranes<\/option><option value=\"for washing wounds\">for washing wounds<\/option><option value=\"roughly\">roughly<\/option><option value=\"in ear\">in ear<\/option><option value=\"intake\">intake<\/option><option value=\"inhalation\">inhalation<\/option><option value=\"other\">other<\/option><\/select><\/span> \n<label>Date of completion of the study<\/label> <span class=\"wpcf7-form-control-wrap\" data-name=\"databadaniafinish\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"databadaniafinish\" \/><\/span>\n<label>Dosage<\/label> <span class=\"wpcf7-form-control-wrap\" data-name=\"dawkowanie\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"dawkowanie\" \/><\/span> \n<label>Cause of use or statistical number of the disease<\/label> <span class=\"wpcf7-form-control-wrap\" data-name=\"przyczynauzycia\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"przyczynauzycia\" \/><\/span>\n<label>Drug suspected of causing symptoms<\/label> <span class=\"wpcf7-form-control-wrap\" data-name=\"lekobjawy\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"lekobjawy\" value=\"Yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"lekobjawy\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n<button type=\"button\" class=\"uacf7_repeater_remove\">usu\u0144<\/button><\/div><\/div><div class=\"uacf7_repeater_controls\"><input type=\"hidden\" class=\"uacf7-repeater-count\" name=\"uarepeater-120_count\" value=\"\"><span class=\"uacf7_repeater_button_wraper\"><button type=\"button\" class=\"uacf7_repeater_add\">Add another drug<\/button><\/span><\/div><\/div>\n\n\t\t\t<p class=\"uacf7-buttons\">\n\t\t\t\t<button class=\"uacf7-prev\"\n\t\t\t\t\tdata-form-id=\"12765\">Previous<\/button>\n\t\t\t\t<button class=\"uacf7-next\"\n\t\t\t\t\tdata-form-id=\"12765\">Next<\/button>\n\t\t\t\t<span class=\"wpcf7-spinner uacf7-ajax-loader\"><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t\n\n\t\t<div class=\"uacf7-step uacf7-step-12765 step-content\"\n\t\t\tnext-btn-text=\"Next\" prev-btn-text=\"Previous\">\n\t\t\t\n<span style=\"font-size:16px;font-weight:600;color:#004F9F;line-height:20.11px;\">Step 5:<\/span><span style=\"font-size:18px;font-weight:400;color:#004F9F;line-height:20.11px;\"> Additional information<\/span>\n<label>(e.g., previous reactions to the drug, risk factors, results of additional tests)<\/label>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"informacjedodatkowe\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"informacjedodatkowe\"><\/textarea><\/span>\n<label>Adverse effect of a medicinal product - this is any adverse and unintended effect of a medicinal product<\/label>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"acceptance-275\"><span class=\"wpcf7-form-control wpcf7-acceptance\"><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"acceptance-275\" value=\"1\" aria-invalid=\"false\" \/><span class=\"wpcf7-list-item-label\">The administrator of your personal data is Przedsi\u0119biorstwo Produkcji Farmaceutycznej HASCO-LEK S.A. with its registered office in Wroc\u0142aw, at ul. \u017bmigrodzka 242e. Your personal data will be processed for the purpose of reporting and handling a medical incident. 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