For Physicians and Pharmacists - Joint Stock Company Olainfarm

Trade name, drug form, active substance and manufacturer	Indications for use	Route of administration	Dose, units, frequency	Start date	End date	Batch/ Series No.	Are the drugs taken for the first time in life?	If drugs were applied earlier, were the reactions similar?
Trade name, drug form, active substance and manufacturer	Indications for use	Route of administration	Dose, units, frequency	Start date	End date	Batch/ Series No.	Are the drugs taken for the first time in life?	If drugs were applied earlier, were the reactions similar?

Trade name, drug form, active substance and manufacturer	Indications for use	Route of administration	Dose, units, frequency	Start date	End date	Batch/ Series No.
Trade name, drug form, active substance and manufacturer	Indications for use	Route of administration	Dose, units, frequency	Start date	End date	Batch/ Series No.

REPORTER (doctor or pharmacist)
Name*
First Last
Phone
Email
SPECIALITY/QUALIFICATION
(physician, pharmacist, other health professional : please – specify)
Date of report
Office Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
ADDITIONAL INFORMATION

(e.g.: on serious concomitant disease, allergic reactions, increased drug sensitivity, pregnancy, significant laboratory test results)
Agreement*
I understand that by signing and/or sending the report I give the permission to the staff of JSC Olainfarm to contact me in order to clarify the information referred to into the report and ask the necessary questions.
- I agree.

ON PATIENT INFORMATION