This form is to allow a rapid initial report to be made. It is not the primary ADR document. Our Pharmacovigilance Department will review all submitted data and make direct contact with you to gather more information on the suspected ADR if required.
Reports can only be accepted for consideration if the following items are included:
The form cannot be submitted without all of the above information being included. Any additional information that can be provided at this stage is useful, but lack of full information should not delay the initial report being made.
It is the reporter's responsibility to obtain the patient's authority if disclosing non-anonymised details. Any information provided will be used by the Alinter Group exclusively for the purposes of ADR monitoring. This may include sharing the information with national regulatory authorities in the UK, EEA and third countries.
Submission of this form implies consent to the above.