Pharmacovigilance

Step 1

I agree to provide my personal data

I agree to be contacted by a company representative

If you answered "yes" to both, continue to Step 2

Step 2

Complete the form below and, when finished, press the Submit button.

Complaint intake form and/or possible
suspected adverse reaction (SAR) report

For reporting and record purposes

If you are NOT the patient, complete this form

Reporter details (Family member - Physician)

Full name:

*Telephone:

*Mobile phone:

Email:

*Relationship to the patient:

If you are the patient, complete this form

Patient details

*Full name and/or initials:

*Age:

Sex: F M

*Approximate weight:

*Telephone:

*Mobile phone:

Email:

*Product:

*Batch/Lot number:

*Complaint/Adverse effect:

(Brief description)

Note: fields marked with * and in bold are mandatory.