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
2. Patient Information
3. Product Information
Please indicate the date of implantation if it has already been performed
4. Information on Adverse Reaction / Quality Issue