ADVERSE EVENT REPORTING FORM 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
