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Avexima invites pharmaceutical distributors and pharmacy chains to cooperate. We will be happy to answer all your questions by phone or e-mail:

+7 495 258-45-28
INFO@AVEXIMA.RU
MOSCOW 31A LENINGRADSKY AVE. Building 1, 125284

Drug safety request for medical information Leave a request about the quality of the drug

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Production Sales Warehouse Office

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Provide information on the safety of the drug (for the patient)

Medicinal product ^*

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stage 1/5

Report
an undesirable reaction

Sender Information

Patient Information

Information about the suspected drug

Description of the event related to the safety and efficacy of the drug

Additional information

Sender's qualifications ^*

Healthcare Specialist / Medical worker

Sender's full name ^*

Sender's phone number and/or e-mail ^*

Patient's initials (for example, IOA) ^*

Patient's gender ^*

Male

Female

Pregnant

Yes

No

Gestation period in weeks

Age ^*

years

years
month
days

Patient's weight (kg)

Treatment

Outpatient

Stationary

Self-medication

Concomitant diseases

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Pernicious habits

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The presence of allergies

Yes

No

Unknown

What are you allergic to?

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Trade name of the medicinal product ^*

Form of release

Indication for use (for what purpose the drug was taken)

Characters left: 300

Route of administration (for example, by injection)

Single dose

Суточная доза

Start date of taking the drug

The end date of taking the drug

Manufacturer

Serial number

Description of the adverse reaction (describe it in as much detail as possible) ^*

Characters left: 1000

The country where the event took place

Date of the start of the adverse reaction

End date of the adverse reaction

Actions taken

Without treatment Reducing the dose of the suspected drug Drug therapy Cancellation of suspected drug Cancellation of concomitant treatment Non-drug therapy Other

Characters left: 300

Criteria for the severity of an adverse reaction

Death Threat to life Hospitalization or its extension Disability Congenital anomalies / malformations A clinically significant event Suspected transmission of an infectious agent through a drug Not applicable

Outcome

Recovery without consequences Condition improvement Unchanged status Recovery with consequences Death Unknown

Concomitant therapy

Yes

No

Detailed description of the information, including drug names, dosage regimens, and dates of use

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Other additional information

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Medical Information Request Form

FULL NAME

You

Doctor Pharmacist / Pharmacist Consumer (patient, patient's relative, etc.) Avexima employee Other option

Preferred way to receive a response

By phone By e-mail

Phone number

Email address

Subject of the request

Avexima drug name

Text of the request

I confirm that by submitting a request for medical information I consent to the processing of the personal data specified in the request form. ^*

I confirm that I am a healthcare professional and that my request for medical information is spontaneous/unprovoked. ^*

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Leave a request about the quality of the drug

The person reporting a problem with the quality of the medicinal product

FULL NAME

Status

Name of the legal entity

Your e-mail or phone number

City

Information about the medicinal product and the essence of the treatment

Name of the medicinal product

Serial number

Manufacturer

Description of the problem with the quality of the drug

Photos showing a problem with the quality of the drug, including photos with the batch number of the drug

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