Adverse Drug Reactions Reporting Form

 

If you suspect that an adverse reaction may be related to a certain drug, or a combination of drugs, you should complete this form and send it to the address shown at the end of
the card.
 
Please report all serious and minor adverse reaction. 
 
Please note that the information taken in the below form is confidential and totally protected including both the patient and reporter identity.
You can send voluntarily the Adverse Drug Reactions (ADRs) Reports to ATOS Pharma.
Reporting for ADRs is vital for save use of drugs. Enough information will hellp to evaluate the safety of the drugs marketed in our country.

 


Patient Details

kg

 


Suspected Drugs

 


Suspected Reaction(s)

 


List Of Other Drugs Taken:

 


Reporter Details

 


Further Information

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