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 SyriMed (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.
© 2021 Copyright Syri Ltd. Head Office Address Syri Ltd t/a SyriMed Unit 4, Bradfield Road, Ruislip, Middx. HA4 0NU UK
Item code 2020/007Date of preparation August 2020