Contact us - Report Adverse Reaction

ADVERSE REACTIONS

If you have taken any of our medicine and would like to report an adverse raction, please fill out the Adverse Reaction Form below and Walmark Pharmacovigilance team will get in touch with you immediately.

CONTACT OUR PHARMACOVIGILANCE TEAM

“Your safety is our primary concern„

Romana Skálová, M.D.

Local Pharmacovigilance officer (LPO)
+420 724 616 509

ADVERSE REACTION report

Adverse reaction description:^*

Date of suspected adverse reaction occurrence:

1 / Information about the person suspected of having an adverse reaction

Year of birth/age:^*

GENDER
MAN WOMAN

Aditional health information
(Chronic diseases, allergy, pregnancy..):

In order to objectively evaluate your report of suspicion of an adverse reaction, please leave your contact details and you will be immediately contected by our specialist.

FULL NAME:^*

Fill out at least one of the following two data to not be associated with the above case, only for contacting our specialist for any additional information.

Telephone:^*

E-mail:^*

2 / Information about the medicinal product suspected of causing the adverse reaction

Name of medicinal product:^*

Product administered (month/day/year)

Used from:
Used to:

Daily dosage:

Batch number:

Use of any other medication:

3 / Information about the course of adverse drug reaction

Did reaction subside after drug withdrawal:

Did reaction appeared again after re-use:

Did you visit a doctor?:

^*Required fields

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