The report on adverse reaction must include the following information:

• reporter’s full name, profession, name of institution, address and phone number;

• patient's initials, age, sex and weight;

• suspected our medicinal product: dosage, mode and duration of usage and treated disease;

• information on adverse reaction: duration (start and end dates) and treatment results (the patient recovered, is recovering, not recovered), was it approved by a physician; assessment of drug relatedness (suspicious, possible, presumptive, undisputed);

• other diseases;

• information on other taken drugs: dosage, mode and duration of usage (start and end dates), indications.

Filled in forms should be returned by mail , fax or e-mail .

Your report will be analyzed and submitted to competent institutions for further processing.

Thank you for your cooperation.

Greta Astrauskaitė - Qualified Person Responsible for Pharmacovigilance