Contact Global Pharmacovigilance

Please fill in the fields as accurate as possible. It there are fields you cannot fill in, please write "unknown". Fields marked with must be filled in.

Please use the date format DD-MMM-YYYY (Example 25-FEB-2014). If you do not know the exact date, please state as close as possible (Example NOV-2014).

If you have further relevant information, please use the field 'Additional information'

Reporting side effects on LEO Pharma products

PATIENT INFORMATION
Patient's initials (only state the first letter in the first name and surname and not the full name): 
Gender*:
 
Pregnant?
 
Age at the time of the side effect:  
Weight: 
Are you the patient?
 
DRUG INFORMATION
Name of LEO Pharma drug used: 
Lot/batch no. of LEO Pharma drug (if available): 
Name of the disease for which this LEO Pharma drug was used: 
First date of treatment with the LEO Pharma drug: 
Daily dose of the LEO Pharma drug: 
Has treatment with the LEO Pharma drug been stopped?
 
If yes on which date did the treatment stop? 
SIDE EFFECT INFORMATION
Which side effect(s) did the patient experience? 
At what date was the side effect(s) first noticed? 
Describe what happened (how did the side effect(s) start, 
Has the patient suffered from the same side effect(s) previously?
 
If yes, please specify which drug(s) was taken at the time: 
How is the side effect(s) right now?
 
 
 
Did the side effect(s) following use of the LEO Pharma drug lead to any of the following?
 
 
 
 
 
If the side effect(s) following use of the LEO Pharma drug lead to death please specify the date the patient died  
OTHER DRUG INFORMATION
Were other drugs taken at the same time as the side effect(s) occurred?
 
If yes, please list the following information:
a) The name of the drug(s): 
b) The disease(s) for which the drug(s) was taken: 
c) The start date: 
DISEASE INFORMATION
At the time of the side effect to the LEO drug, was the patient suffering from any other disease, including allergies?
 
If yes please describe the following:
a) Disease: 
b) Date started: 
c) Treatment prescribed: 
ADDITIONAL INFORMATION
Please use this field for further relevant information: 
REPORTER INFORMATION
Your name: 
Country:  
Are you a Health Care Professional?
 
If yes, please specify type: 
e-mail address (a copy of the form will be sent to this e-mail): 
Please press the 'send' button in order for LEO Pharma to receive your side effect report

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