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Adverse Reaction Reporting

Please fill in the fields as accurately as possible. If there are fields you cannot fill in, please write "unknown". Fields marked with an asterisk must be filled in.

Please use the date format DD-MMM-YYYY (Example 25-FEB-2023). If you do not know the exact date, please enter the closest possible date.

If you have further relevant information, please use the field "Additional information".

To understand how LEO Pharma handles the personal information you provide, please click here to view our privacy statement.

Reporting side effects on LEO Pharma products

PATIENT INFORMATION
Gender *
Pregnant? *
Are you the patient?
DRUG INFORMATION
Has treatment with the LEO Pharma drug been stopped? *
SIDE EFFECT INFORMATION
Has the patient suffered from the same side effect(s) previously? *
How are the side effect(s) right now? *
Did the side effect(s) following use of the LEO Pharma drug lead to any of the following?
OTHER DRUG INFORMATION
Were other drugs taken at the same time as the one where the side effect(s) occurred? *
If yes, please list the following information:
DISEASE INFORMATION
At the time of the side effect(s) to the LEO Pharma drug, was the patient suffering from any other disease, including allergies? *
If yes, please describe the following:
ADDITIONAL INFORMATION
REPORTER INFORMATION
Are you a healthcare professional? *
Do you agree to be contacted again for further information, if necessary? *
Disclaimer *
Consent *
Data protection *