* Notification of an Undesirable Reaction
You can inform us of a suspected undesirable reaction in free form, in which case please indicate the following:
• Your name, surname, profession, company name, address and telephone number;
• The initials of the patient, his/her age, gender and weight;
• The product suspected of causing the reaction, dosage, consumption and the duration of its consumption, the illness being treated;
• Information on the suspected undesirable reaction: duration (dates for the start and end) and outcome (the patient has recovered, is recovering, the URD continues, etc.), whether the URD has been confirmed by a doctor; an evaluation of the link to the drug’s consumption (suspected, possible, likely, certain);
• Accompanying illnesses;
• Information on other drugs in use: their dosage, mode of consumption, duration (dates for the start and end), indications.
Please send the completed form:
- by mail address: Moletu road 11, LT-08409 Vilnius, Lithuania; or Taikos av. 102, LT-51195 Kaunas, Lithuania;
- fax +370 5 2701223;
- e-mail NRV@valentis.lt
We sincerely thank you for your co-operation.