The following form should be completed by the healthcare professional. If you are a patient, his guardian or representative go to the form intended for you.
Please complete this form in as much detail as possible. If you are unable to complete any section please leave it blank
Please be advised that the personal data collected in the report will be processed by Syri Ltd.t/a Thame Laboratories (Unit 4, Bradfield Road, Ruislip - Middlesex, HA4 0NU, United Kingdom) and used exclusively for the purposes related to the obligation that is placed by regulatory authorities on companies holding marketing authorisations for medicines to monitor the safety of the medicines they market.
Item code 2018/38 Date of preparation Sept 2018