CARD-NOTIFICATION for providing information by the patient and/or his representative about an adverse reaction (hereinafter referred to as ADR) of a medicinal product (hereinafter referred to as MD), and/or lack of efficacy (hereinafter referred to as EE) of a MD Patient information Name Name Patronymic Address Tel./Fax Information about the suspected drug Trade name Release form Producer The suspect drugs were prescribed to the patient by a doctor YesNo The patient used the suspected drugs without a doctor's prescription. YesNo Description of drug adverse reactions and/or indications of drug EOs Information about the reporter Name Name Patronymic Address Tel./Fax Email address Information about the doctor, healthcare facility, and place of residence of the patient who experienced a drug adverse reaction and/or drug adverse reaction Name Name Patronymic Location of the healthcare facility (Address) Name of the healthcare facility where the attending physician works Tel./Fax Patient's place of residence (Address)
