Medicinal Safety

Instructions for Completing the Form

Feel free to send a message, even if you don’t have all the necessary information to fill out the form!

This document is confidential! The information from your messages is processed in strict compliance with the principle of confidentiality. The patient’s identity is never revealed.

Please use this form to report all suspected adverse drug reactions observed when using medicinal products of the company “Chemax Pharma EOOD”.

We will gratefully accept all messages sent by doctors, dentists, pharmacists and other meds. Specialists. Patients who believe that they have experienced side effects from their prescribed medications can report this through their treating physician.

We remind the medical professionals that they are obliged, according to the requirements of ZLPHM, to report to the Medicines Executive Agency (EMA) and the Marketing Authorization Holder any suspected serious or unexpected adverse reaction, regardless of whether the medicinal product is used or not in compliance with the approved Summary of Product Characteristics.

NLR Report Form

PLEASE COMPLETE AND SUBMIT TO: Deputy CLLB

Adverse drug reaction report
OF a Chemax Pharma EOOD product

    Fields marked with an asterisk (*) are required.

    *Patient Data




    *Suspected Drug








    *Adverse Reaction







    Concomitant Treatment








    *Name and Contact Details of the Reporter





    Chemax Pharma collects and processes your personal data (Names, email address and other data, depending on the information entered), provided through this form, in order to administer your inquiry.

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