Webform UK

Reporter information

What is your country/location?

First name

Last name

Phone number

E-mail

Confirm e-mail

Check if you are a Sobi employee

Check if you are a Healthcare Professional

Healthcare Professional type

Check if you do not wish to be contacted for any follow-up communication

Information about the person who experienced the side effect

I am reporting as:

Patient initials

Gender

Age at the time of the side effect

Information about the medicine

Please list the Sobi product which you suspect could have caused the side effect(s).

Name of product

Product dosage and frequency

Describe dosage formulation

What was the indication (reason for use)?

When did the patient start/stop using this product?

Start date

End date

Unknown start date

Unknown end date

The use of the product is still ongoing

Batch/Lot number

Side effect description

Please list the side effect(s) which you would like to report.

Country where the event occurred

Side effect(s)

Describe details of the side effect and provide additional relevant information

Describe the side effect in more detail, including which impact the side effect had and if any treatment was needed. You may also include other relevant information, such as medical history, concomitant medications, healthcare professional details, or any other information that may help us assess the report.

What date did they first/last experience their symptoms?

Symptoms start date

Symptoms end date

Was the patient hospitalized or did the event cause death?

Yes, hospitalized

Yes, death

No, neither

Please upload any relevant documents

Reporter information

Information about the person who experienced the side effect

Information about the medicine

Side effect description

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