Consumers - Biopharma

A notice
of adverse action to the drug for consumers

The key task of Biopharma is to provide consumers with effective and safe medicines. Therefore, we will be grateful for providing reliable information on the detection of adverse effects or the lack of efficiency of our products. This will help us to improve the Biopharma drugs.

01. Information about drug (medicine)

Brand name *

Formulation

Manufacturer *

02. description of the adverse reaction or an indication of a lack of effectiveness*

required field *

03. Information about reporter

Full name *

Address

e-mail
tel./fax *

04.Information about patient

Full name *

Age

Diagnosis
Address

Sex MaleFemale

tel./fax In case the reporter is not a patient

05. Drug administration information

The drug was assigned to a patient by a physician yesno

The patient used the drug without a doctor's appointment yesno

06. Information about the doctor and the health care institution

Full name of physician

Healthcare institution's name

Healthcare institution address

tel./fax

A noticeof adverse action to the drug for consumers

A notice
of adverse action to the drug for consumers