Print the form and fill in with all information you have on the adverse drug reaction. If you are the doctor please confirmed it with signature and stamp.

• Adverse drug reaction to doctor notification form
• Adverse drug reaction to patient notification form

Please, transfer the form to our Company representative or send it to the address below:

Medical Department
Bausch Health Poland sp. z o.o.
ul. Przemysłowa 2
35-959 Rzeszów
faks: + 48 44 789 00 36
e-mail: dzialania.niepozadane@valeant.com

You can also notify the adverse drug reaction by phone or email:

Phone numbers:

+ 48 724 182 068