Report an Adverse Event or Product Quality Concern

Your safety is our priority. If you or someone you care for has experienced a reaction, side effect, or product quality issue with an Amerisyn medicine, please complete the form below so we can review it and follow up appropriately.

Adverse Event & Product Quality Reporting Form

Please share as much as you can. All reports are reviewed by our quality and pharacovigilance team. Some fields are required.

WHO ARE YOU?

Healthcare ProfessionalPatient or CaregiverAmerisyn Employee or Vendor

WHAT ARE YOU REPORTING?

Adverse Drug Experience (s)Product Quality Complaint(s)

YOUR DETAILS

Name

Mobile Number (with Country Code)

City

Postal Code

Country

PATIENT DETAILS

If you're reporting on behalf of someone else, please share what you can – we'll keep this confidential.

Patients Name (kept confidential)

Age

Gender

Weight

Race/Ethnicity (optional)

CONSENT

I, the patient or reporter, consent to Amerisyn contacting me via:I, the patient or reporter, consent to Amerisyn contacting me via:EmailPhoneEither

DETAILS OF THE PRODUCT BEING REPORTED

Product Name

Lot Number (if available)

Indication for Use

Dosage

Start Date

Stop Date

Still taking this product/ongoing

DESCRIBE ADVERSE EVENT OR QUALITY COMPLAINT

What happened, and when did it start?

OUTCOME

What has been the outcome so far?What has been the outcome so far?Fully RecoveredRecoveringCondition UnchangedCondition WorsenedFatalUnknown

SERIOUSNESS

Did any of the following occur as a result of this event?Did any of the following occur as a result of this event?DeathHospitalizationLife-ThreateningPermanent Disability or incapacityBirth DefectNone of the Above

RELEVANT MEDICAL HISTORY

Please share any relevant medical history, allergies, or pre-existing conditions.

OTHER MEDICATIONS

Is the patient currently taking any other medications?Is the patient currently taking any other medications?YesNo

If yes, please list the medication name(s), dose, and frequency.

ADDITIONAL INFORMATION

Is there anything else you would like us to know?

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