mAbxience | farmacovigilancia

Pharmacovigilance

mAbxience Pharmacovigilance (for adverse event reporting)

Manuel Pombo Angulo 28 3rd floor, Madrid
Postal code: 28050 Spain
Phone: +34 606 361 702
Fax: +34 917 189 265
Email: pharmacovigilance@mabxience.com
 

1. THE MEDICINE

What´s the name of the product for which you want to report a side effect?

ABOUT THIS MEDICINE

How is this medicine related to the side effect?

WHEN AND WHY THIS MEDICINE WAS TAKEN:

When did the person experiencing the side effect start taking the medicine?

Start Date:
End Date:

WHY DID THEY TAKE THIS MEDICINE?

HOW THE MEDICINE WAS TAKEN?

Which formulation of the medicine were they taking?

 

How did they take it?

 

What dose were they taking?


 

How often did they take it?

 

What action was taken with the medicine as result of the side effect?

ADDITIONAL INFORMATION

Lot or batch No.

2. SIDE EFFECT

What is the side effect you want to report?

ABOUT THE SIDE EFFECT

What was the outcome of the side effect?

 

How long did the patient experience the adverse event?

Start Date:
End Date:

DESCRIBE THE SIDE EFFECT IN MORE DETAIL AND IF ANY TREATMENT WAS NEEDED:

SERIOUSNESS

What was the side effect serious?

 

How serious was the side effect?

3. PATIENT

ABOUT THE PERSON EXPERIENCING THE SIDE EFFECT

What is the gender of the person experiencing the side effect?

DETAILS ABOUT THE PERSON

What are the initials of the person who experienced the side effect?

 

How old was the patient at the time of the side effect?


 

What was their height?


 

What was their weight?


 

What is their date of birth?

 

What is the patient’s medical history?

 

Please provide results of tests/labs, medical history, allergies, etc. Do not provide any patient identifiable information (e.g. name, DOB) in this box

4. CONTACT DETAILS

REPORTER AND CONTACT INFORMATION

What is your country?

CONFIRMATION OF THIS REPORT

What is your email address?

CONTACT INFORMATION

Type of reporter

 

Can we contact a health care professional if we need more information about your report?

 

Can we contact a you if we need more information about your report?

 

Contact Details