Adverse Event Reporting Form

* Fields marked with an asterisk are required.

If you experience any adverse event related to the products, you may report it through www.welfar.com.tr or by writing to safety@welfar.com.tr for national and international reporting. You may also report it via our corporate pharmacovigilance line, available 24/7, at +90 538 278 89 91, or by completing and submitting the form below. By reporting any adverse events, you will contribute to obtaining further information about the safety of the medicine you are using.

Name

Surname

Phone Number

Email Address

Product

Adverse Event / Suspected Side Effect

Patient’s Name

Patient’s Surname

Patient’s Gender

Patient’s Date of Birth

Patient’s Height (cm)

Patient’s Weight

I Agree

In order for us to contact you regarding your adverse event / undesirable effect / adverse reaction report, please share your phone number or other contact information with us. All details you share with us will be kept confidential and will not be shared with any individual or company, except for the institutions and organizations with which sharing is required in accordance with legal regulations and procedures regarding patient privacy.

By selecting the “I Agree” checkbox, you acknowledge that you consent to the recording, storage, and processing of your personal data. By selecting the “I Agree” checkbox, you also acknowledge and declare that you accept the legal notice and the validity of the information you have entered.

Information: During the follow-up of adverse event / undesirable effect / adverse reaction reports, we may need to contact you. Therefore, you must provide a valid phone number or email address so that we can get back to you. By accepting the terms and conditions within the scope of the Personal Data Protection Law, you declare that you have read and accepted this text.