Adverse Event Reporting

Source

HospitalizedDeathLife ThreateningCongenital AnomalyNone of these


Reporter Details


Patient Information

MaleFemale

Date of Birth


Do you provide consent for further follow-up by our pharmacovigilance department regarding adverse event information that may be required?


Product Details

Did event/s reappear after drug was reintroduced?

Did event/s diminish after drug stopped/dose reduced?


Start Date of Use

Stop Date (if applicable)


Expiry Date

Manufactured Date

Action Taken


Adverse Event Details

Adverse Event/s Start Date

Adverse Event/s Stop Date (if applicable)

Outcome of Event

Was treatment received?


Concomitant Medication

Only answer below questions if YES

YesNo

Date Started

Stop Date (if applicable)


Other relevant information, if applicable:

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In case of a medical emergency, please contact your local HCP for further assistance