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Działania Niepożądane

Pola oznaczone gwiazdką (*) są obowiązkowe.

Wypełnij formularz przeznaczony dla pracownika ochrony zdrowia.

Dane osoby, u której wystąpiło działanie niepożądane

Lek lub leki podejrzewane o to, że mogły spowodować działania niepożądane:

Inne równolegle stosowane produkty lecznicze oraz informacje dodatkowe:

Inne stosowane produkty lecznicze oraz daty rozpoczęcia i zakończenia ich podawania, wskazania, dawkowanie, które były stosowane w tym samym czasie, co lek(i) podejrzewane o spowodowanie działania niepożądanego (z wyłączniem produktów leczniczych zastosowanych w związku z leczeniem działania.)

Dane osoby raportującej:

Wszystkie informacje i dane osobowe, które nam przekazałeś/przekazałaś w zgłoszeniu działania niepożądanego będą chronione i zachowane w poufności zgodnie z Polityką Spółki oraz przepisami prawa.Podane informacje będą przetwarzane w celach związanych z nadzorem nad bezpieczeństwem stosowania produktów leczniczych (i w celu umożliwienia nam należytego zajęcia się Pani/Pana zgłoszeniem) i mogą być przekazywane organom administracji właściwym w sprawach ochrony zdrowia, jeśli wynika to z przepisów prawa.Ma Pani/Pan prawo dostępu do treści swoich danych osobowych oraz ich poprawiania.

Podanie wskazanych powyżej danych, oznaczonych symbolem * - jest obowiązkowe na podstawie art. 36e Ustawy z dnia 6 września 2001 r. - Prawo farmaceutyczne. Podanie pozostałych danych jest dobrowolne.Administrator danych osobowych: Accord Healthcare Ltd (Sage House, 319 Pinner Road, North Harrow, Middlesex, HA1 4AF, Wielka Brytania).Podanie wskazanych powyżej danych, oznaczonych symbolem * - jest obowiązkowe na podstawie art. 36e Ustawy z dnia 6 września 2001 r. - Prawo farmaceutyczne. Podanie pozostałych danych jest dobrowolne.Administrator danych osobowych: Accord Healthcare Ltd (Sage House, 319 Pinner Road, North Harrow, Middlesex, HA1 4AF, Wielka Brytania).

Dane kontaktowe osoby raportującej:

Podanie poniższych danych nie jest obowiązkowe, ale może nam ułatwić analizę zgłaszanego przez Panią/Pana działania niepożądanego, jeśli wymagałoby to kontaktu celem uzyskania dodatkowych informacji.

Informacje zawarte w formularzu są poufne i mogą być wykorzystywane jedynie zgodnie z ustawą z dnia 6 września 2001 r.– Prawo farmaceutyczne. Wyrażam zgodę na przetwarzanie moich danych osobowych dla potrzeb niezbędnych do monitorowania bezpieczeństwa produktów leczniczych (ustawa z 10 maja 2018 r. o ochronie danych osobowych).

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Accord Healthcare Ltd Board of Directors
October 2019