Pharmacovigilance Form

You can use the form below to report an adverse drug, medical device or dietary supplement reactions/ adverse events including overdose, drug, medical device or dietary supplement abuse/misuse, medication errors, “off label use”_ pregnancy or occupational exposure.

Please send us a message to pharmacovigilance@pharmaselect.com or fill out the form!

Contact person

Professional group*

medical specialty*

please specify

Gender

Date of birth

First name*

Surname*

Address

Location

Zip code

Country*

E-Mail*

Phone

Fax

Information about the affected patient

Gender*

Date of birth

First name (first letter)

Surname (first 3 letters)

Affected medicinal product/medical device/food supplement

Name of the drug/medical device/food supplement*

Reason for using the drug/medical device/dietary supplement

Batch number

Description of side effect(s)

Description of side effect(s)*

Date of occurrence

Outcome of side effect(s)

please specify

We are legally obliged to document and evaluate reports that have become known and, if necessary, to report them to the Federal Institute for Drugs and Medical Devices in accordance with the statutory provisions. Please give us your consent to pass this information on to the federal authorities by ticking the preceding selection box. The form can only be sent once you have given us your consent. All patient and doctor-related data given on the report form will be treated confidentially in accordance with the provisions of the Federal Data Protection Act. Your report makes a relevant contribution to the evaluation of the side effect profile of our product and thus to the safety of the treatment.