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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?
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)
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.
I have read and understood the
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