Dear Healthcare Professional,

To notify about adverse drug please fill in the form with the following information

1. Information about the Patient (initials, date of birth, age, age group or sex)
2. Information about Healthcare Professional reporter (name or initials, address or qualification, contact details)
3. At least one suspected active substance/medicinal product
4. At least one suspected adverse reaction

Please send the signed form to the following address or fax:

Farma-Projekt Sp. z o.o.
Specjalista ds. Monitorowania Bezpieczeństwa Farmakoterapii
Maja Ludwikowska
Ul. Józefińska 2
30-529 Kraków

m.ludwikowska@farmaprojekt.pl
tel. +48 12 421 18 51
tel kom + 48 692 447 088
fax +48 12 294 04 82

CIOMS FORM ON ADVERSE DRUG REACTION - pdf version

The information in the form is confidentail and may be used only in compliance with the regulation of the Minister of Health dated 17 February 2003 (item 405) on monitorng the safety of medicinal products.