Adverse reactions

If you (or someone known) has had a side effect to one of our medications, you can notify us directly by filling out the form below.

The information that you provide us can help us in our work to identify the side effects not previously recognized and, therefore, improve the safe use of medications. We encourage you to also notify the side effects that are described in the package leaflet.

Thank you very much for your help.
Laboratorios ESTEDI S.L.

FORM to notify ADVERSE REACTIONS

PATIENT'S DATA*

Sex:
Age:
Indicate the correct unit for the AGE that you have entered, tell us if you are talking about:
Enter date of birth:  
Age group:
Weight (Kg):
Height (cm):
*Please, select at least 2 boxes of the above, thank you.

PREVIOUS OR CURRENT DISEASES

Enter disease:
Start date:
Ending date:
Comments:
Do you wish to add another disease? SíNo
Enter disease nº2:
Start date:
Ending date:
Comments:
Do you wish to add another disease? SíNo
Enter disease nº3:
Start date:
Ending date:
Comments:
Do you wish to add another disease? SíNo
Enter disease nº4:
Start date:
Ending date:
Comments:
Do you wish to add another disease? SíNo

Please, in case you have more diseases to add use this text field to list them adding in each case: Name of the disease, date of beginning and end of the disease and any other comments that you consider appropriate, thank you.  

DATA OF ADVERSE REACTION (RAM)

RAM:

Enter here the RAM that you have experienced:
Start date:
Ending date:
Outcome:
Gravity:
If you marked "serious", indicate us:
Enter country where RAM has occurred:
Have you informed your doctor of RAM? SíNo
Do you give us permission to contact your doctor about this RAM? SíNo
If yes, and you give us your permission, enter the following contact information please:
Name:
Surnames:
Address:
Telephone contact:
E-mail contact:
Is it a RAM related to a medication error? SíNo

*Medication error: It is an unintentional failure in the process of medication treatment that causes or may cause harm to the patient. It may be related to prescription, dispensing and / or administration.

Do you wish to add another RAM? SíNo

RAM nº2 :

Enter here the RAM that you have experienced:
Start date:
Ending date:
Outcome:
Gravity:
If you marked "serious", indicate us:
Enter country where RAM has occurred:
Have you informed your doctor of RAM? SíNo
Do you give us permission to contact your doctor about this RAM? SíNo
If yes, and you give us your permission, enter the following contact information please:
Name:
Surnames:
Address:
Telephone contact:
E-mail contact:
Is it a RAM related to a medication error? SíNo

*Medication error: It is an unintentional failure in the process of medication treatment that causes or may cause harm to the patient. It may be related to prescription, dispensing and / or administration.

Do you wish to add another RAM? SíNo

RAM nº3 :

Enter here the RAM that you have experienced:
Start date:
Ending date:
Outcome:
Gravity:
If you marked "serious", indicate us:
Enter country where RAM has occurred:
Have you informed your doctor of RAM? SíNo
Do you give us permission to contact your doctor about this RAM? SíNo
If yes, and you give us your permission, enter the following contact information please:
Name:
Surnames:
Address:
Telephone contact:
E-mail contact:
Is it a RAM related to a medication error? SíNo

*Medication error: It is an unintentional failure in the process of medication treatment that causes or may cause harm to the patient. It may be related to prescription, dispensing and / or administration.

Do you wish to add another RAM? SíNo

RAM nº4 :

Enter here the RAM that you have experienced:
Start date:
Ending date:
Outcome:
Gravity:
If you marked "serious", indicate us:
Enter country where RAM has occurred:
Have you informed your doctor of RAM? SíNo
Do you give us permission to contact your doctor about this RAM? SíNo
If yes, and you give us your permission, enter the following contact information please:
Name:
Surnames:
Address:
Telephone contact:
E-mail contact:
Is it a RAM related to a medication error? SíNo

*Medication error: It is an unintentional failure in the process of medication treatment that causes or may cause harm to the patient. It may be related to prescription, dispensing and / or administration.

Do you wish to add another RAM? SíNo

Please, in case you have more RAM to add, use this text field to list them, adding in each case the information provided in the previous RAM's and any other comments that you consider appropriate, thank you. 

MEDICATION DATA

Medication:

Enter medication name:
Start date:
Ending date:
Role of the medicine*:

*Concomitant: A drug that was used at the same time as the suspected drug but that you think is not related to RAM.

Indication:
Dosage (posology):
Lot:
Pharmaceutical form:
Route of administration:
Action taken with the medicine:
Do you wish to add another medication? SíNo

Medication nº2:

Enter medication name:
Start date:
Ending date:
Role of the medicine*:

*Concomitant: A drug that was used at the same time as the suspected drug but that you think is not related to RAM.

Indication:
Dosage (posology):
Lot:
Pharmaceutical form:
Route of administration:
Action taken with the medicine:
Do you wish to add another medication? SíNo

Medication nº3:

Enter medication name:
Start date:
Ending date:
Role of the medicine*:

*Concomitant: A drug that was used at the same time as the suspected drug but that you think is not related to RAM.

Indication:
Dosage (posology):
Lot:
Pharmaceutical form:
Route of administration:
Action taken with the medicine:
Do you wish to add another medication? SíNo

Medication nº4:

Enter medication name:
Start date:
Ending date:
Role of the medicine*:

*Concomitant: A drug that was used at the same time as the suspected drug but that you think is not related to RAM.

Indication:
Dosage (posology):
Lot:
Pharmaceutical form:
Route of administration:
Action taken with the medicine:
Do you wish to add another medication? SíNo

Please, in case you have more medications to add, use this text field to list them, adding in each case: Name of the medication, start and end date, indicate if it is suspicious or concomitant, the indication, the batch, the dose , the pharmaceutical form, the route of administration and the action taken with the medicine, thank you. 

NOTIFIER DATA

Name*:
Surnames*:
Organization/Department*:
Address (Street, Plaza, Avenue, ...):
Number:
City*:
Postal Code*:
Province:
Country:
Telephone contact:
E-mail contact*:
Do you know if your doctor or pharmacist have notified the RAM to the authorities? SíNo
If we need more information to understand the case, do you give us permission to contact you directly? SíNo
Are you notifying additional information about a case that you had previously notified? SíNo
*You must indicate at least City, P.C. and telephone or E-mail.



The information you provide will be managed according to our Personal Data Protection Policy. Confirm that you understand by checking the box.