Safety Related Form Report For Suspect Safety-Related Events Adverse Events / unwanted reactions Interactions Overdose Abuse / misuse Medication error Lack of efficacy Off label use Occupational exposure Transmission of infectious agent Use during pregnancy / breastfeeding SUSPECT PRODUCT* BATCH EXP. DATE REPORTER (NAME)* Is the reporter health professional? Yes No DATE E-MAIL PHONE Address / address of the establishment (for health professionals)* EVENT: Description what happened and when.PATIENT: Please provide at least one of the information mentioned below (age, gender, initials).Age Gender Initials SOURCEOTHER RELEVANT INFORMATIONPhoneThis field is for validation purposes and should be left unchanged.
