FORM OF CARD-MESSAGE

for employees with medical and / or pharmaceutical education

Required fields *

Patient Information

Patient Name

First Name

Last Name

No of outpatient card/ madical case history

Sex

Age (at the moment of reaction)

Body weight (kg)

Country

Occurrence of pathology

Hepatic disorders

Comment:

Renal diseases

Comment:

Pregnancy (duration, weeks)

Comment:

Allergy (point out that)

Comment:

Information about the drug

Brand name

International Nonproprietary name (INN)

Drug form

Batch

Dosage, dosage frequency, administration route

Therapeutic indication

Start date of drug intake

YYYY

End date of drug intake

YYYY

Information about the adverse effect

Definition of adverse effect (including data of laboratoty and instrumental studies) or lack of efficacy

Start date of adverse effect

YYYY

End date of adverse effect

YYYY

Was the removal of the suspect drug accompanied by the disappearance of the adverse effect?

Has the recurrence of the adverse effect been noted after re-appointment of the suspected drug?

Action taken

Comment:

Drug therapy of advarse effect

Fate

Seriousness criterion of adverse effect

Comment:

Information about medical and/or pharmaceutical employee

Employee name

Position (profession)

Address

Phone number

Country

(###)

###

####

E-mail

Receipt date of information about adverse reaction

YYYY

Date of filling out of Form

YYYY

Consent for processing of Personal Data

I hereby express my written, unconditional and irrevocable consent to the processing of my Personal Data by M.Biotech Limited containing in the form which I have filled in. Processing of personal data includes committing any action and/or a set of actions associated with collecting, registering, accumulation, archiving, adaptation, changing, modification, usage and distribution (transmission), depersonalization, destruction of my personal data, for the purpose of processing the request which I have sent or to provide a response to my question. The extent of my personal data according to which processing is occurred and which can be contained in the M.Biotech Limited company database of Personal Data is represented as information about me (indicated in the form I’ve filled in), which became known to M.Biotech Limited company. The consent to the processing of my Personal Data does not require the M.Biotech Limited company to provide information about my Personal Data transferring to third parties, according to the provision of Article 21 of the Law of Ukraine ‘Protection Personal Data’. I confirm that I understand the rights established by the Law of Ukraine ‘Protection Personal Data’, as well as the purpose of processing my Personal Data, including collecting them. I agree that the term of my Personal Data processing is unlimited.

I hereby agree for the processing of my personal data

FORM FOR DOCTORS

M.Biotech LIMITED

STRENGTHS & ADVANTAGES

20 years experience in Eastern Europe and Central Asia

Extensive networks and informal contacts

Highly professional regulatory team

Extensive coverage and knowledge of local tenders and other public biddings

Good networks of leading national distributors in respective territories

Experience in obtaining of confirmation of GMP certificates in Ukraine for many Indian and European companies

Manufacturing plants of M.Biotech Limited have high quality European equipment