Esteve | Adverse reactions

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NOTIFICATION OF SUSPECTED ADVERSE REACTION TO A MEDICINE

Have you reported this adverse reaction to the Spanish Agency of Medicines and Medical Devices (AEMPS)?

INFORMATION ABOUT THE PATIENT

Name

Surname

E-mail*

Telephone

Gender*

Birthdate

Year of birth*

Location*

Country*

INFORMATION ABOUT THE PRODUCT

Provide the name of the medicinal product suspected of causing the adverse reaction*

Why were you receiving the medication?

What was the daily dose?

What was the administration route?(e.g. oral, topic, inhalation route)

What were the dates of treatment? (start date, end date, or if you are still taking it)

Did you discontinue the medication?

Indicate if you were taking other medicines, and which:

INFORMATION ON THE ADVERSE REACTION

Describe what happened to you*

Did the adverse reaction resolve favorably?

Indicate the start and end (if resolved) date of the adverse reaction

Did you receive any treatment for the adverse reaction?

ANOTHER INFORMATION

Please indicate if you have suffered or suffer from any disease

Have you ever notified this reaction to your physician?*

Do we have your permission to contact your physician?*

Please indicate contact data (telephone, e-mail…) of your physician so that we can obtain as much information as possible on your adverse reaction and follow it up*

Please add any comment you may deem relevant

I am read and accept the legal Notice and the privacy policy.

Data Controller	Esteve Pharmaceuticals, S.A., with Tax nº A-08037236 and registered office at Passeig de la Zona Franca, 109, 4ª Planta, 08038, Barcelona (Spain), Sole-Shareholder company. More info
Purposes and legal basis	Analyze, send and notify to the health authorities the information regarding notifications of adverse effects, as well as to monitor such notification. The legal basis for this data processing is compliance with legal obligations in terms of pharmacovigilance. More info
Third parties	Your personal data may be transferred to other Esteve group companies, as well as to companies with which we maintain marketing license agreements and other third parties for the fulfillment of legal obligations. More info
Rights	Esteve will not collect, register nor perform any processing of patients or consumers personal data. More info
Additional information	Fore more information, please consult our Privacy policy

Data Controller	Esteve Pharmaceuticals, S.A., with Tax nº A-08037236 and registered office at Passeig de la Zona Franca, 109, 4ª Planta, 08038, Barcelona (Spain), Sole-Shareholder company. More info
Purposes and legal basis	Analyze, send and notify to the health authorities the information regarding notifications of adverse effects, as well as to monitor such notification. The legal basis for this data processing is compliance with legal obligations in terms of pharmacovigilance. More info
Third parties	Your personal data may be transferred to other Esteve group companies, as well as to companies with which we maintain marketing license agreements and other third parties for the fulfillment of legal obligations. More info
Rights	You may exercice your rights of access, rectification, erasure, and objection, among other rights, as detailed in the additional information. More info
Additional information	Fore more information, please consult our Privacy policy

Adverse reactions

Notification form

NOTIFICATION OF SUSPECTED ADVERSE REACTION TO A MEDICINE

INFORMATION ABOUT THE PATIENT

INFORMATION ABOUT THE PRODUCT

INFORMATION ON THE ADVERSE REACTION

ANOTHER INFORMATION

NOTIFICATION OF SUSPECTED ADVERSE REACTION TO A MEDICINE

HEALTH PROFESSIONAL CONTACT DATA

INFORMATION ABOUT THE PATIENT

MEDICAL HISTORY

INFORMATION ABOUT THE SUSPECT PRODUCT

INFORMATION ABOUT CONCOMITANT MEDICATION

INFORMATION ON THE ADVERSE REACTION

OTHER INFORMATION