Report a side effect

Report from a patient or a patient's representative

If the condition is life-threatening, call the emergency number (112 in most countries, 103 in Ukraine).

Required fields are marked with an asterisk (*) and a pink border. The border disappears when the field is filled in.

About you Who you are Who is sending the report: the patient or another person.

How to contact you — fill in at least one of the three fields (required)

Name How to address you. A first name or initials are enough. Up to 200 characters. Phone So that a pharmacovigilance specialist can clarify the details. Up to 33 characters. E-mail So that a pharmacovigilance specialist can clarify the details. Up to 200 characters.

Country The country where you are.

About the patient

Do not write the patient's surname and first name — initials are enough.

Fill in at least one: initials, year of birth, age or sex (required)

Patient's initials First letters of the surname and first name, for example “TP”. The full name is not needed. Up to 60 characters. Year of birth Four digits, for example 1956.

Age at the time of the reaction (if the year of birth is unknown) If the year of birth is unknown. Under 3 years — in months, under a month — in days. Age unit

Sex The patient's sex.

Weight, kg If known. Height, cm If known.

Other diseases, allergies Chronic diseases, allergies; if pregnant — the week of pregnancy.

Medicine that may have caused the reaction

Side effect

If there was no reaction (for example, the medicine was taken during pregnancy without consequences), leave this block empty or remove it and describe the case under “Describe the case in your own words”.

Other medicines the patient was taking (optional)

Describe the case in your own words (optional)

Do not write the patient's surname and first name — initials are enough.

Description What happened, when and in what circumstances.

Doctor (optional) Name a doctor we may contactOptional. Only if you are the patient or the patient's legal representative.

Documents and photos (optional)

You can add a medical summary, test results or a photo of the medicine package (with the batch number and expiry date). Up to 5 PDF, JPG or PNG files, each up to 10 MB, 20 MB in total.

Before adding a document, cover the patient's surname, first name, address and medical record number.

Optional, but it helps a lot to assess the case: when the reaction started, how serious it was, how it ended, other medicines, a description, files.

Thank you! Your report has been received.

Report from a patient or a patient's representative