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PHARMACOVIGILANCE : NOTICE OF ADVERSE EVENT

This section is for healthcare professionals.
If you are patient you should contact your doctor. If you have questions regarding non-medical products you can call +54 (011 ) 5555-1600 Monday through Friday from 9:00 to 16:30 business hours. Or write through this flap CONTACT.
If you are a doctor or healthcare professional and need to report an adverse event, please complete the next form or call +54 (011) 5555-1600 Monday through Friday from 9:00 to 16:30 business hours.

PATIENT DATA

Name
Last Name
Weight
Age
DESCRIPTION OF ADVERSE EVENT (INCLUDING DURATION)
Relevants complementary exams (date and result)
Base disease and relevants medical conditions
(allergy, pregnant week, alcohol, drugs, hepatic or renal dysfunction, tabaquism, etc.)
Concomitant medication (including alternatives therapies)
Death Date

SUSPECT DRUGS

Generic name
Comercial Name
Dose, frequency and route of administration
Start of therapy
End of therapy
Use indication
Expiration date
Batch Nº

¿Did the suspension or reduction in the dose of the suspected drug cause minimization or disappearance in the adverse event?

¿Did the same or similar adverse event reappear after reintroduction of the suspected drug?

Reaction onset
Date of this report

COMUNICATOR DATA

Lastname and Name
Address
Phone
Job place
Profession