Report adverse drug reaction

Data identifying patient:
Sex:
FemaleMale
Date of birth:

Age:

Patient initials:

Drug that caused ADR:
BIOTON products:*
[medicines_select]
Serial number:

Daily dose:

Route of administration:

Route of first administration*:
From

To

Description of ADR*:

Date of ADR:

Symptoms:

Severity of ADR:
selectlife-threatinghospitalization or extension of a stay in hospitalpermanent or significant disability or impairmentfetal malformations / birth defectsother severe adverse reactionnon-severe adverse reaction (does not meet the above criteria)death
Result of ADR:
chooserecovery without lasting consequencesrecovery with lasting consequencescurrently undergoing treatment for symptomsother
Concomitant drugs:

Additional information:

Personal data of the ADR reporter
ADR reporter:*
[text* ]
chooseDoctorPharmacistNurseDentistPatient/Carer

Name and surname:*

Address:*

Email:*

Phone number:*

Attending physician:
Do you agree for us to contact the attending physician for obtaining further details?
NoYes; if you agree, please provide the contact details of the attending physician.