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Patient & Health Care Professional

UAE
Completed : 0%
  • Step 1
    Patient details
  • Step 2
    Product
  • Step 3
    Event
  • Step 4
    Medical
  • Step 5
    Review

    Patient and Reporter Information

    Patient Details

    Please Provide a response to at least 1 of the fields marked with a* (in RED)

    If reporting from within the EEA or the UK, please provide initials ONLY. Provision of other identifiers is optional.

    MaleFemale
    PregnantNot PregnantUnknown

    Please provide your information

    Selecting 'Yes' will require some of the contact information fields above to be filled.

    YesNo
    YesNoI am the healthcare professional

    Healthcare Professional Information

    Cancel Report

    Product information

    Please provide information for the Vieco product(s) for which you would like to report:

    Add products one at a time and select 'Add Another' as needed.

    eg. 20 mg twice a day

    Include prescribed medicines, store bought medicines, dietary supplements and herbal remedies

    YesNoUnknown
    Cancel Report

    Adverse Event Information

    HospitalizationProlongation of existing hospitalization (treatment received during existing hospitalization)Life threatening illness (immediate risk of death from the event)Disability or permanent damagePatient diedCongenital anomaly or birth defectNone of the above
    YesNoUnknown
    ProbablePossibleUnlikelyUnknown
    Cancel Report

    Additional Information

    Cancel Report

    REVIEW

    This adverse event, contact details and the personal information provided shall be handled by Vieco in accordance with Vieco's Privacy Policy, which is available at the link below View Vieco's Privacy Policy



    Cancel Report
    tankyou

    Thank you for your submission

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