Reporting Form Side Effects

REPORTING FORM

You can use this form to report any suspected side effects or quality complaints relating to CO.DON’s medicinal products.

The fields marked * must be completed. Since we are obliged by law to contact you if we have any questions, your contact details will also be kept on file. The optional information helps us to make a better assessment of the (potential) side effect or your (quality) complaint.

In all cases the personal data in your report and all other data that may serve to identify you are concealed by means of a pseudonym in accordance with statutory provisions when they are entered into our safety database.

1. Reporter Information

You are *

Name *

Country *

Phone *

Email *

May we contact you with questions? *

2. Patient Information

Year of Birth *

Gender *

3. Product Information

Product name *

Batch No.

Date of Biopsy *

Date of ImplatantionPlease indicate the date of implantation if it has already been performed

treated joint *

Name of Joint / Knee Area

4. Information on Adverse Reaction / Quality Issue

Start Date

End Date

Adverse Reaction is ongoing

Detailed description of the Adverse Reaction or of quality issue*

The potential Adverse Reaction led to *

Adverse Reaction

Comments

I have read the advice on data protection in connection with reports of side effects and quality complaints. *