Notification of side-effects

This page gives you the opportunity of reporting any adverse drug reactions (ADRs) resulting from the use of medac’s medical products. Please make use of the ADR form which we have specially provided for you. As a rule you will receive an acknowledgement of your message, and further information if you request it.

Our preparations are subject to continuous monitoring in the light of the benefit to risk profile. So as to make it possible for us to take any necessary steps, the notification of side effects is an essential prerequisite, and we would ask you please to contribute in any way you can.

For urgent issues having to do with pharmaceutical safety we can be reached even out of normal business hours. If you call our central switchboard on +49 (0)4103 8006-0, your call will be forwarded in case of need. In a case of symptoms requiring urgent treatment, please contact the emergency services.

Patient details

These data are needed to identify duplicate reports and to facilitate identification of the affected patient in case of questions.

Initials (first and last name)

Age *

Date of birth

SEX

female

male

Weight (kg)

Height (cm)

Study / observation study

no

yes

If study/observational study, please specify:

Underlying disease

Preparations (before occurrence of undesirable side-effects)

Product(s)/ substance(s) I *

Manufacturer and batch number I

Dose and unit I

Route of administration I

Therapy dates (from/until) I

Indication(s) I

Suspected causal relationship?

yes

no

Product(s)/ substance(s) II

Manufacturer and batch number II

Dose and unit II

Route of administration II

Therapy dates (from/until) II

Indication(s) II

Suspected causal relationship?

yes

no

Product(s)/ substance(s) III

Manufacturer and batch number III

Dose and unit III

Route of administration III

Therapy dates (from/until) III

Indication(s) III

Suspected causal relationship?

yes

no

Product(s)/ substance(s) IV

Manufacturer and batch number IV

Dose and unit IV

Route of administration IV

Therapy dates (from/until) IV

Indication(s) IV

Suspected causal relationship?

yes

no

If there is no suspicion of a causal relationship with the medac product, please specify the suspected cause (e.g. underlying disease, comorbidities)

Relevant history and comments

Contact details

Reported by

Physician

Pharmacist

Patient

Other

Your name *

Your address

Your telephone number

Your e-mail address *

Fields marked with an asterisk (*) are required.

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