Adverse Event Report

1. Reporter Details

PatientCarerHealthcare ProfessionalOther

2. Patient Information

FemaleMaleOtherPrefer not to say

3. Suspected Medicine

4. Adverse Event

Ongoing
RecoveredRecoveringNot recoveredUnknown
NoYesUnknown

5. Other Relevant Information

NoYesUnknown
NoneAvailable

6. Privacy

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