Adverse Event Reporting


HospitalizedDeathLife ThreateningCongenital AnomalyNone of these

Reporter Details

Patient Information


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


Date Started

Stop Date (if applicable)

Other relevant information, if applicable:


Type the characters above

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