Reporting side effects

In case of medical emergencies please contact immediately your doctor, pharmacist and / or the emergency department.

Please complete the following formulary and then click “Submit"

1. To whom does this report apply?

This report is about (*)
mea child / my childanother person

2. Informations about the patient who experienced the side effect.

Name, Last Name or Initials (*)

Birthday (*)

Sex (*)
MaleFemaleRather not say

3. Informations about the drug that is suspected to have caused the side effect.

Drug name and dose (e.g. Rokivit D3 28000IE) (*)

Dosage (e.g. 400 mg twice daily) (*)

4. Informations about the experienced side effect.

Description of the signs / symptoms (e.g. itching, redness etc.) (*)

5. Additional information.

Give as much details as possible (optional)

6. Informations about the reporter.

Name, Surname (*)

Telephone (*)

Your email (*)

Address (*)

Town (*)

Country (*)

The patient and the reporter are the same person? (*)
YesNo