Side Effects

THANK YOU FOR YOUR CONTRIBUTION TO MAKING MEDICINES SAFER.

Information on the product

The name of the product: including the concentration of the drug, the amount and number of times the drug was used, for example 100 ml vial used once a week. *

The batch number(s) of the medicinal product used

The indication for use of the medicinal product: the intended reason behind prescribing this medication.

When did the patient start using the medication and when was it stopped or given last time?

Was the administration of the medication changed because of the side effect (for example, reduce the dose or discontinued the medicinal product)? And did this help to ease the side effect?

Information on the side effect(s):

What is (are) the side effect(s) *

When did the side effect(s) start?

Did the patient need to stay in hospital because of the side effect?

Yes
No

Has the patient received specific treatment because of the side effect(s)? If yes please specify:

Did the patient recover or is the side effect ongoing?

Information on the patient:

Initials of the name of the patient (please write only the initial letters of the patient’s name; for example, Ahmed Sueiman writes the initials as (A.S.) 2 *

Gender of the patient

Age of the patient (years, months, or days at the time of the side effect, please do not give birth dates)

Further information on the patient:

Weight (in kg) and/or height (in cm)

Any other medical conditions the patient suffers from at the moment:

Any other medicinal product(s) that the patient currently takes (name of the medicine, the concentration of the medicinal product, number of daily doses, and the date the patient started taking the medicine).

Information on the treating physician

Can we get additional information from the treating doctor? If yes, please provide us with the doctor’s contact information.

Doctors name and contact details

Information on the reporter

Reporter name and contact details *

Are you a healthcare professional (physician, pharmacist, registered nurse) *

Yes
No

By checking this box, I give my consent to Biotest and its representative in Saudi Arabia to contact me through the given contact information methods.

Information privacy policy

I have read and understood the privacy policy and agree that my contact details are saved and processed to answer and deal with my enquiry. I am aware of my right to withdraw consent at any time as described in the privacy policy. By joining this event, I hereby confirm that my participation in the event will not influence with my behavior in relation to procurement channels, prescription and prescription practice towards patients and/or pricing and that such expectation does not exist. My participation in this event will not result in any act or conduct which would violate relevant applicable laws or applicable professional codes of conduct and standards regarding anti-corruption and transparency.

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