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Pharmacovigilance
The Company continuously monitors the safety of the Company’s medicinal products by collecting and evaluating information on adverse reactions.
If you would like to report an adverse reaction or lack of efficacy of a company’s medicinal product, you can fill out the form below or contact a pharmacovigilance specialist.
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Map-message from consumers
A notification card for providing information by a patient and/or his/her representative, organizations representing patients' interests, about an adverse reaction and/or lack of efficacy of a medicinal product during its medical use
Step 1/6Information about the patient
Last Name*
Name*
Middle name*
Step 2/6Information about the suspected medicinal product
Trade name*
Manufacturer*
Pharmaceutical form*
Step 3/6Information on the prescription of the suspected medicinal product
The suspected drug was prescribed to the patient by a doctor*
The patient used the suspected drug without a doctor's prescription*
Step 4/6Description of adverse reactions or indication of lack of efficacy*
Step 5/6Information about the messenger
Last Name*
Name*
Middle name*
Location*
Tel./fax*
Step 6/6Information about the physician and healthcare facility at the place of residence of the patient who experienced an adverse reaction or lack of efficacy
Last Name*
Name*
Middle name*
Location of the healthcare facility*
Tel./fax*
Card-message from medical staff
Report card on adverse reaction (AR) and/or lack of efficacy (LOE) of a medicinal product (MP) in its medical use
Step 1/8Subject of the appeal
Select the topic of your appeal*
Step 2/8General information
Full Name of the Patient*
Weight (kg)*
Height (cm)*
Medical history/outpatient record number*
Date of birth of the patient*
Sex*
Consequence of the PR/CE*
Step 3/8Information about the suspected medicinal product (MP), MP manufacturer
Start of PR/WE*
End of PR*
Description of PR / specification of WE of the medicinal product (including data from laboratory and instrumental studies related to PR)*
Outcome of PR/WE*
Step 4/8Information about the suspected medicinal product
PLP (trade name, dosage form)*
Manufacturer, country*
Series number*
Indications for prescription (if possible, indicate the ICD-10 code)*
Single dose*
Frequency of administration*
How to enter*
Start of therapy*
End of PLP therapy*
Step 5/8Information about concomitant medicinal products (excluding those used to correct the effects of PR)
Concomitant medicinal products (trade name, dosage form, manufacturer)*
Indications (if possible, according to ICD-10)*
Single dose*
Frequency of administration*
Method of entry*
Start of therapy*
End of therapy*
Other important information (diagnoses, allergies, pregnancy with duration, etc.)
Step 6/8Means of PR correction
Discontinuation of PLP*
Did the discontinuation of PLP coincide with the disappearance of PR?*
Re-initiation of PLP*
Was there a recurrence of PR after the re-initiation of PLP?*
Change in the dosage regimen of PLP (зниження/підвищення, зазначити, на скільки):*
Was there a recurrence of PR/WE after changing the dosage regimen of PLP?*
Was no correction of PR performed?*
Pharmacological therapy of PR/WE (specify medicinal products, dosage regimen, duration of administration):*
Step 7/8Causal relationship between the clinical manifestations of PR and PLP
Step 8/8Information about the messenger
The message provides*
Full name of the notifier, phone/fax*
Name and location of the healthcare facility or notifier*
*Fields required to be filled in
Contact person
Contact a pharmacovigilance specialist by phone around the clock to report adverse reactions or lack of efficacy of the drug.
Phone (24/7) +38 067 262 90 87
