Through this form, Laprophan collects your personal data in order to manage all risks related to adverse effects caused by any of our medicine and / or manage the contact with healthcare professionals who have reported such an effect. The personal data communicated may be transmitted to our principals or to the supervisory authorities. You may contact Laprophan to exercise your rights of access, rectification and opposition in accordance with the provisions of Law 09-08

LAPROPHAN S.A."Pharmacovigilance" Registration form

1. Patient :

Initials :
Sex :

2. Suspected Medicine :

3. Prescribed for :

4. Description of the Adverse Event :

5. Patient Reactions :

Disappearance of effect after discontinuation of drug :
Reappearance of effect after recovery of drug :
Has this medication been taken before? ?
(with or without) Adverse effet :

6. Medical history and concomitant diseases (allergies, pregnancy, others ...)

7. Related Medicines : (specify form / way of administration / dose)

Posologies/ Day
Posologies/ Day
Treatment :

8. Gravity criteria (effect followed by) :

9. Evolution of the event :

10. Implemented measures (against the adverse effect) : :

11. Information / Additional Examination :

12. Appreciation Causality: Relationship between the suspected medicine and the adverse effect :

13. Notifier :