Product Details

Product details*

Action taken as a result of side effect*

Treatment DiscontinuedTreatment ContinuedTreatment InterruptedUnknown

Side Effect Details*

Country in which Event Occurred

Select CountryAustriaBelgiumBulgariaCroatiaRepublic of CyprusCzech RepublicDenmarkEstoniaFinlandFranceGermanyGreeceHungaryIrelandItalyLatviaLithuaniaLuxembourgMaltaNetherlandsPolandPortugalRomaniaSlovakiaSloveniaSpainSwedenUK

Seriousness*

Resulted in DeathWas Life ThreateningResulted in DisabilityResulted in Birth Defects or Congenital AnomalyResulted in Hospitalisation or its ProlongationMedically Significant

Outcome of Side Effect*

Complete RecoveryCondition DeterioratedCondition ImprovingCondition UnchangedFatal or DeathRecovered with SequelaeUnknown

Reporter Details

ProfessionHealth Care ProfessionalNon-Health Care Professional

Reporter ConsentCan ContactCannot Contact

Select CountryAustriaBelgiumBulgariaCroatiaRepublic of CyprusCzech RepublicDenmarkEstoniaFinlandFranceGermanyGreeceHungaryIrelandItalyLatviaLithuaniaLuxembourgMaltaNetherlandsPolandPortugalRomaniaSlovakiaSloveniaSpainSwedenUK

Relation with PatientSelfFriendSpouseRelativeTreatingDoctorNurseOther

Reporter contact details

Patient DetailsSelfOther

Gender of the PatientMaleFemaleCross GenderUnknown

Medical History*

Additional documents to be attached(If any)

Please submit any relevant documents as an attachment and email to safety@amaroxpharma.com, Tel number +44(0)2039720005