24/7 telephone contact for medical questions and side effects: +359888896587 – dr. Vili Topalova
INSTRUCTIONS FOR FILLING IN THE FORM
While filling in this form, you could communicate all the probable adverse drug reactions (ADR), which are being observed when using the medicinal products of our company.
Do not hesitate to send a message if you believe that you experienced an adverse drug reaction when using our products.
After receiving the feedback form, we will immediately try to contact you for additional information and clarification. The information you fill in is confidential!
We process the information from the messages in strict conformity with confidentiality, and do not disclose the personal data in all cases. If you do not agree for your personal information to be used in the abovementioned manners and would like to refuse its processing or would like to get access; correct or erase your personal information, please inform us via email at the following address firstname.lastname@example.org.
We would be grateful to receive all the messages being sent by doctors, dentists, pharmacists and other medical specialists. The patients that are believed to have experienced adverse drug reactions due to the drugs prescribed for them, could communicate about that and consequently the data should be confirmed by the attending doctor.
The feedback form contains the following sections:
Data about the person who provides the information – the data are necessary for accepting the communication as an authentic one and for feedback (confirmation of the message reception, assessment results, sending additional information, if necessary).
Information about the patient – initials, age and sex, whereas at least one field should be filled in as a rule. These data are essential in order to avoid duplicating the messages, for assessment and should we need to follow up the case.
Suspected drug – short description of the suspected drug, appellation, daily dose, start, end, outcome. In some cases we suspect only one drug as the reason behind the adverse reaction, even if the patient is undergoing combined therapy. Then in this column we fill in only information about this drug, and the other drugs should be defined in the next section.
Other non-suspected drugs – In this section we note all the drugs the patient is taking simultaneously with the suspected drug.
Adverse drug reaction – we need short description of the reaction, start, duration, outcome, additional information you believe it is important.
Please bear in mind that the fields marked with asterisk (*) are mandatory!
Please fill in as much data as possible, because this is important for assessing your message.