Reporting
an adverse
drug reaction

Please complete this form to report adverse drug reactions observed with the use of Vedra International AD products or distributed by Vedra International AD.

Please note that some fields marked with an asterisk (*) require mandatory completion for your message to be accepted as valid. However, we ask you to fill in as much data as possible, because it is important for the evaluation of your message.

After pressing the send button, the completed form will be sent to: safety@vedrainternational.eu, drugsafety@avpharm.com

I. REPORTER DETAILS

II. PATIENT DATA

Gender*:

male female

III. DATA ABOUT THE SUSPECTED MEDICINE

When was the medication started:

When was the medicine last taken:

IV. DATA ON THE SUSPECTED ADVERSE DRUG REACTION

When did the adverse drug reaction occur and how long did it last:

What is the outcome of the adverse reaction:

Please add additional information that may be relevant - test results, other illnesses, allergies, smoking, drug abuse, alcohol, drugs, pregnancy, breastfeeding, etc.

Reportingan adversedrug reaction

I. REPORTER DETAILS

II. PATIENT DATA

III. DATA ABOUT THE SUSPECTED MEDICINE

IV. DATA ON THE SUSPECTED ADVERSE DRUG REACTION

Reporting
an adverse
drug reaction