Ticket

Online Form for Medical Inquiries, Complaints, Adverse Reaction Report

Reporter Information

Helpdesk-Team

Typ of Request

Subject

E-Mail

Title

First name

Surename

Organisation

Department

Address (Street)

Postal code ZIP

City

Country

Telefone

Mobile

Prevered Language

German

English

Reporter Type

Doctor

Pharmacie

Patient

Nurse

Family member

Business Partner

Product Information

Product/Tade name

Batch Number(s)

Product Category

Pharmaceutical Product

Medical Technical Product

Food Supplements

Product Sample

Comments to Sample

Indication for use

Daily dosis

Route of Administratiom

Begin of Treatment

End of Treatment

Duration of Use

Duration of Use before

Reaction Details

Describe Reaction(s)

Date of Reaction

Duration of Reaction

Life threatening

Patient hospitalised

Hospitalisation prolonged

Congenital anomaly or birth defect

Persistent or significant disability/incapacity

Patient deceased by side effect

not applicable

Action

Drug discontinued

Drug continued

Dosage changed

Therapy

Outcome

Restored

Improved

Unchanged

Worsen

Fatal

Unknown

Patient Information

Patient Initials

Date of birth

Gender

Male

Female

Height

Weight

Week of pregnancy

Relevant Medical History

Nicotine

Alcohol

Allergies

Drug abuse

Metabolic disorder

Other

Risk Descritption

Remarks

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