DAVERIS

DAVERIS

Prescription drug for use in ophthalmology. Antiglaucoma drugs and myotics. Analogues of prostaglandins.

Eye drops, solution

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CARD-NOTIFICATION OF AN ADVERSE DRUG REACTION AND/OR LACK OF EFFICACY OF THE MEDICINE

INFORMATION ABOUT THE PATIENT

SUSPECTED AR/LE

Suspected AR (describe each clinical manifestation of the AR with dates and times of onset and end and outcome)/Indication of the LE

INFORMATION ABOUT SUSPECTED MEDICINES

INFORMATION ABOUT RELATED MEDICINES

(with the exception of drugs used to correct the effects of AR/LE)
(concomitant diagnoses, laboratory and instrumental studies, allergy history, pregnancy with gestational age, method of conception, pregnancy outcome (if the pregnancy ended, the date of delivery, type of delivery, etc.)

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MESSAGE CARD for the patient

to provide the patient and/or his/her representative with information on adverse drug reactions and/or lack of efficacy of the drug

INFORMATION ABOUT THE PATIENT

Information about the suspected medicine

Information on the prescription of the suspected medicinal product

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Information about the physician, healthcare facility and place of residence of the patient who had an adverse medicine reaction and/or lack of efficacy of the medicine

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