Form for
doctors / specialists

A doctor or other person reporting HP

Name (required)

Position and place of work

Institutional Address

Phone

Email (required)

Date

Treatment:

Ambulatory

Stationary

Self-treatment

Report

First report date

Patient Information

Initials

№ ambulatory card or medical history

Gender

Male

Female

Age

Weight

Additional information

Pregnancy

Liver disorder

Impaired kidney

Allergy

What is allergic to

Presumptive Drug

International Nonproprietary Name (INN)

Trade Name (TN)

Manufacturer

Country

series number

Indication for appointment

Medicine route

Single/daily dose

Therapy start date

Discontinuation Date

Discovery date

HP dose

Other drugs taken over the past three months, including drugs taken by the patient on their own (by their own decision)

International Nonproprietary Name (INN)

Trade Name (TN)

Medicine route

Therapy start date

Discontinuation Date

Indication

I agree to the processing of personal data (required)

Thanks! Form Submitted Successfully.

Thanks!

Your data has been sent successfully!

Form for doctors / specialists

Form for patient/family

Send a resume

Feedback

Form for
doctors / specialists

Form for
patient/family