For non-medical staff


Form for reporting adverse reactions by non-medical staff

The information you provide is extremely important to detect suspected adverse reactions towards medicinal products authorized for use on the territory of Bulgaria. We will need your contact details for feedback purposes to confirm receipt of the message, and if necessary to request additional information and inform you of the measures taken. We assure you that the personal data of the reporter / patient is treated in accordance with the Personal Data protection Act. Identification number of Bestamed Ltd. for processing of personal data: 414601.

Please note that some fields marked with an asterisk (*) require mandatory filing to accept your message as valid. However, we ask you to fill in as much data as possible, because it is important for the assessment of your message.


You fill in this message as

Reporter's data

Please provide your contact details by filling in at least one of the following fields so that your message to accepted as valid; preferably - phone number.

@
Patient's data
Information about the suspected medicine
Information about suspected adverse reaction
  • recovery
  • recovery with consequences
  • undergoing recovery
  • continuing adverse reaction
  • the adverse reaction caused. death
  • unknown
  • other
  • cause some discomfort
  • caused disability
  • caused hospitalization
  • caused life-saving actions
  • caused invalidity
  • other

Do you admit that the experienced adverse reaction was caused by a non-intentional mistake at the time of prescription, distribution at the pharmacy, preparation or administration of the pharmaceutical product and it so, please explain?

Please, explain the reason in your opinion, which resulted in the experienced adverse reaction non-intentional mistake at the time of prescription, distribution at the pharmacy, preparation or administration of the pharmaceutical product.

Results from tests, other diseases, allergies, smoking, abuse with medicinal products, alcohol, drugs, pregnancy, breastfeeding, etc.

If you agree that we may search for additional information on your case by your treatment doctor, please, fill in his contact data



Fill in generated symbols.
Code is lower and upper case sensitive.