Reporter Name *
Reporter Type *
Healthcare Professional (e.g., Doctor, Pharmacist, Nurse)
Patient
DKSH Taiwan Ltd. employee, Business partner, distributor
Caregiver/Friend/Relative
Others
Reporter Contact Phone *
Reporter Email *
Patient Initial/or Last name (e.g. Wang, Da-Ming’s initial is WDM, or fill in ‘’Wang’’) *
Patient Age Range *
0 – 12 years old
13 – 18 years old
19 – 40 years old
41 – 64 years old
Over 65 years old
Unknown
Unwilling to provide
Patient Gender *
Medical History or Concomitant product *
Are you or your spouse pregnant or breastfeeding *
No pregnant or breastfeeding
I or my spouse is pregnant
I or my spouse is breastfeeding
Unknown
Unwilling to provide
Product Name *
Batch No./ Lot. No *
Indication *
Therapy Duration From *
Therapy Duration to *
Narrative of safety information (Please fill in the chronological order of events as much as possible, including the disease/symptom, onset time and site of adverse event, symptoms, seriousness, action taken and outcome) *
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