* 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.

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