Report A Side Effect

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Country *

Who are you? *

Member of public (eg. yourself, a patient, friend, parent or carer)
Health care provider (HCP)

Product name *

Active Ingredient *

How is this medicine related to the side effect? *

When did the person experiencing the side effect start taking the medicine? *

Start Date
End Date

Why did they take this medicine?

Which formulation of the medicine were they taking?

How did they take it? *

What dose were they taking? *

Other Dosage [e.g. 24/26 mg or other]

How often did they take it?

What action was taken with the medicine as result of the side effect? *

Batch number:

Side Effect *

What was the outcome of the side effect? *

How long did the patient experience the adverse event? *

Start Date
End Date

Please provide below if you consider there is a causal relationship between the event and the suspect product(s) and/or any additional detail(s) for the event(s) or treatment(s)

Was the side effect serious? *

Unknown
No, it was not serious
Yes, it was serious

How serious was the side effect?

Resulted in death
Was life threatening
Resulted in or prolonged hospitalization
Resulted in a disability or was incapacitating
Resulted in a congenital anomaly or birth defect
Medically Significant

About the person experiencing the side effect

Gender *

What are the initials of the person?

Age *

Height

Weight

Date of birth

Patient’s medical history

Please provide results of tests/labs, medical history, allergies, etc: *

Please upload any relevant documents:

Contact Reporter

Email address

Is Reporter the Patient?

Yes
No
Someone I know
A patient I support

Your title:

First name *

Last name

Address line 1

Address line 2

Town/City

Phone number: *

Contact a health care professional

First name *

Last name

Address line 1

Address line 2

Town/City

Country:

Phone number: *

Profession: *

Name of hospital, clinic etc: *

Email Address:

Adverse Event Privacy *

I authorize EIPICo. and any of its affiliates to collect and analyze the information I provide for the purpose of assessing side effects related to my use of an EIPICo.'s product, and to disclose this information to health authorities in my country and other countries around the world as required by law or regulation. All information pertaining to this report, as well as any follow up inquiries for additional medical details, shall be in accordance with the EIPICo. patient safety reporting privacy notice.

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