ADVERSE REACTIONS

If you become aware of any adverse reactions associated with the use of medicinal products, or of any other events that may be related to the safety of the products, we kindly ask you to share this information in any way convenient for you:

FILL OUT THE FORM ON THE WEBSITE.

To begin, please indicate who you are:

Healthcare professional

Patient or other person

Fields marked with an *, — are mandatory.

Step 1. Person reporting the adverse reaction

Your name *
Position *
E-mail *
Phone

Country *
Region / Province *
City / Town *

Step 2. Patient information

Initials *
Outpatient card number or medical record number
Age
Weight
Sex
Male Female
Pregnancy
Yes No Unknown
Gestational age

Type of treatment
Outpatient Self‑medication

Inpatient Unknown
Impaired liver function
Yes No Unknown
Impaired renal function
Yes No Unknown
Allergy
Yes No Unknown
Comorbidities
Medicinal products taken within the last 3 months

Step 3. Information about the medicinal product that caused the adverse reaction

Name *
Indication for use
Route of administration
Dose

Expiry date
Batch
Start date of therapy
Date of last intake before the adverse reaction

Step 4. Description of the adverse reaction

Describe the adverse reaction *

Date of onset of the adverse reaction
Date of resolution of the adverse reaction
Outcome of the adverse reaction

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I have read and agree to the Terms of Use of the Service and the Terms of Use of the Website I consent to the processing of personal data

Your name
E-mail
Phone
Who you are

Country
Region / Province
City / Town
Describe AR

You have not agreed to the website's terms

I have read and agree to the Terms of Use of the Service and the Terms of Use of the Website I consent to the processing of personal data

OR CONTACT US AT:

E-mail: safety@sipeconsult.com

Mailing address: 121596, Moscow, Gorbunova St., 2, Bldg. 3, “Grand Setun Plaza” Business Center, Office A300

Phone: +7 (495) 222-68-99

Scientia Ipsa Potentia Est – Knowledge itself is power

Contact us

info@sipeconsult.com
+7 (495) 222-68-99
Russia: Moscow, Gorbunova St., 2, Bldg 3, A300
Kazakhstan: Karaganda, Ermekova St., 29, Office 307

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