Emergency form for notification of supply failure

Reporting of supply difficulties pursuant to the Danish executive order on removal of medicinal products from Medicine Prices, etc. due to supply difficulties.

Product number

Medicinal product (name)

Pharmaceutical form

Strength

Pack size

Date when supply failure commences

Date of report

Reporting party (company)

Contact person and telephone number

Stamp and signature

Please fill out one form for each product number.

Questions may be addressed to leveringssvigt@dkma.dk.

Wholesalers can send the completed form to:

Danish Health and Medicines Authority
Medicine Prices
Axel Heides Gade 1
2300 Copenhagen S
Denmark

The form can also be sent by email to leveringssvigt@dkma.dk.

Updated 24 April 2012