Adverse Event Reporting

Reporter information

Please provide your contact information (so we can contact you in case of potential follow-up questions)

*mandatory field

Name *Please fill the required field.

Phone or Email *Please fill the required field.

Occupation *Please fill the required field.

Country *Please fill the required field.

Patient information

Please enter the patient's data. You need to complete at least one of the fields.

Patient initials

Date of birth

Age

Age unit

Gender *Please fill the required field.

Adverse event description

Adverse event description *Please fill the required field.

Adverse event onset date

Adverse event cessation date

Adverse event(s) seriousness category

Fatal outcome

Life threatening

The event required patient's hospitalisation or prolongation of an existing hospitalisation

The event resulted in a persistent or significant disability or incapacity of the patient

The event led to a congenital anomaly in the patient's child

Other medically important condition (please provide more information below)

Justification

Treatment details

Please provide more information about the treatment

Suspect drug *Please fill the required field.

Indication(s) for use

Batch number

Administered drug dose

Route of administration

Therapy start date

Therapy end date

Other drugs used shortly before or during the reported adverse event(s)

Other drugs indication(s) for use

Other drugs batch number

Other drugs administered drug dose

Other drugs route of administration

Other drugs therapy start date

Other drugs therapy end date

Patient's medical history

In case you would like to be sent a copy of your report, please provide your email address

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Email: info@alliapharm.com
Phone: +3670 595 4649