Adverse Event Report

1. Reporter Details

PatientCarerHealthcare ProfessionalOther

2. Patient Information

FemaleMaleOtherPrefer not to say

3. Suspected Medicine

4. Adverse Event

5. Other Relevant Information

Other medicines taken:

Relevant medical history / allergies:

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6. Privacy

I confirm the information is correct and understand that Maddox Pharma Swiss will process this report for pharmacovigilance and safety reporting purposes.