Adverse event reporting

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ExtractumPharma Co.Ltd as Marketing authorisation holder (MAHs) shall submit all suspected adverse drug reactions (ADRs) reported spontaneously by healthcare professionals and patients. If you think you or your patient may be experiencing a side effect after using a medicine or a problem involving the use of a medical device, seek advice from a health professional as soon as possible and please also be kind entering your data by filling the form bellow.

 

Patient initials::*
Patient gender:*  
Reporter name:
Reporter  occupation:*
Country:*
Reporter's phone / e-mail address:*
Suspected drug:*
Strength of the drug, batch number, if known:
Other used drugs:
Patient's medical history:*

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* completion of fields marked with the symbol (*) is obligatory; you cannot submit the form without completion of these fields