Reporting of side effects Crescent Pharma always scrutinizes the safety of all its medicinal products collecting information about any side effects patients experience. It is essential that the safety of all medicinal products is monitored throughout their marketed life via the pharmacovigilance process. If a Crescent Pharma product causes a side effect, you can use the form below to inform us of details. Please note Crescent may contact you to find out more details about your report; however, Crescent will not be able to provide medical advice about your condition. Any questions regarding your treatment should be made via your doctor or healthcare professional. IMPORTANT Please note this form is exclusively for use if the drug has been administered; if the drug has NOT been administered please use our ‘Contact us’ form. URGENT CONTACT For urgent medical enquiries out of office hours please contact: Tel: +351 21 464 32 25, Fax: +351 21 464 32 29 or via email to: pharmacovigilance@pharsolution.com. Alternatively you can email us at info@crescentpharma.com or send a fax to +44 (0) 1256 772740 Medical Information Please note this form is exclusively for use if the drug has been administered. Title Mr Mrs Miss Ms Dr Name* First Last Status: Healthcare Professional Patient Organization Address* Street Address Address Line 2 City County / State / Region Post Code Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos Islands Colombia Comoros Congo, Democratic Republic of the Congo, Republic of the Cook Islands Costa Rica Croatia Cuba Curaçao Cyprus Czech Republic Côte d'Ivoire Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini (Swaziland) Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine, State of Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Réunion Saint Barthélemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Islands Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu US Minor Outlying Islands Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Åland Islands Country Phone* Email* Preferred contact method:* By Telephone By Email By Post Product* Has the Product Been Administered?* YES NO If so were there any problems, adverse reaction or lack of efficacy?* Does the enquiry concern a pregnancy:** YES NO Enquiry Details:* Crescent Privacy Policy The information provided in this form will be recorded by Crescent as part of its legal obligations related to our products and will be protected and handled confidentially in line with data protection laws and the Crescent Pharma privacy policy. The information provided may be shared with certain authorities to be evaluated. If you are not the subject of the report, please ensure that person who is the subject of the report is aware of this submission. This should also include the potential transmission of their personal information. © 2021 Designed by Nettl | Web Studio & Marketing Agency Terms & Conditions We use cookies on our website to give you the most relevant experience by remembering your preferences and repeat visits. By clicking “Accept”, you consent to the use of ALL the cookies. Cookie settings ACCEPT