Reporting Adverse Drug Reactions

Name of the reporter*
E-mail*
Phone
Initials of the patient’s name X-X-X*
Age of the patent*
Name of the patient*
- Woman
- Man
Disease for which the medicine has been used?*
Dose that has been used?*
Start date and end date of use for the medicine causing the complaint
Date Format: YYYY dot MM dot DD
Date Format: YYYY dot MM dot DD
Did he/she discontinue the use of the medicine causing the complaint?*
- Yes
- No
Description of the adverse drug reaction
Consent
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4032 Debrecen, Bartha Boldizsár u. 7.

Phone.: +36 52 431 313
Fax: +36 52 431 315
E-mail: info@keri.hu

Reporting Adverse Drug Reactions

Phone.: +36 1 808 0781
(There is an answering machine to ensure 24-hour coverage )