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SUSPECT ADVERSE DRUG REACTION REPORTING FORM

Form for the healthcare professional

Download here CIOMS form   
SUSPECT ADVERSE REACTION REPORTING FORM

Form for non-healthcare professional

If you wish to report to SyriMed any adverse event which you suspect that you or someone you represent has experienced following the use of a SyriMed medicine, please either complete the form below or contact us by email (medinfo@syrimed.co.uk) or by telephone on the following number 02085153700 selecting the option for medical informationand reporting adverse events. If you wish you can send these details by post to SyriMed, Medical Informationand Pharmacovigilance, Unit 4, Bradfield Road, Ruislip HA4 0NU.

You should also tell your doctor or pharmacist of what you have experienced

* Required information

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.