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Adverse Reaction Reporting Form
Adverse Reaction Reporting Form
12Questions
Adverse Drug Reaction Reporting Form
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    • Male
    • Female
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    What happened?
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    • Abiraterone SPC 250mg F.C. Tablets
    • Azacitidine SPC 100mg Injection
    • Bortezomib SPC 3.5mg Pow for Sol for Inj.
    • Capecitabine SPC 150mg F.C. Tablets
    • Capecitabine SPC 500mg F.C. Tablets
    • Docetaxel SPC 20mg/1ml Solution for Infusion
    • Docetaxel SPC 80mg/4ml Solution for Infusion
    • Imatinib SPC 100mg Tablets
    • Imatinib SPC 400mg Tablets
    • Lenalidomide SPC 5mg Capsules
    • Lenalidomide SPC 10mg Capsules
    • Lenalidomide SPC 25mg Capsules
    • Pemetrexed SPC 500mg Powder for Sol for Inf.
    • Zoledronic Acid SPC 5mg/100ml Solution for Infusion
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    • Yes
    • NO
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    Concomitant Medications (any other Medication that the patient is taking) and Medical History (any chronic diseases that the patient has. For example: Diabetes, Hypertension, etc
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    Dear Healthcare Professional,

    • Adverse Drug Reaction (ADR) is a response to a medicinal product which is noxious and unintended. This includes side effects arising from use of a medicine within the terms of the marketing authorization (e.g. the authorized indications), as well as from use outside the terms of the marketing authorization, including overdose, misuse, abuse and medication errors, and suspected adverse reactions associated with occupational exposure.

    • Confidentiality: Reporter's and patient's identity are held in strict confidence by Sudair Pharma and protected to the fullest extent of the law, information provided by the reporter will be strictly protected and will not be used in any way against him / her.

    • Please fill out the reporting form providing the most complete information. Use a separate form for each ADR. Attachment of additional documents (e.g. doctor's records, laboratory results, etc.) are highly appreciated as they would support Sudair Pharma assessment of the event. Kindly submit the completed form to:
      • Pharmacovigilance and Drug Safety Department
      • Tell phone: 920001432 (ex. 107)
      • Fax: + (966) 11 466 8195
      • Email: Pharmacovigilance@SudairPharma.com
      • Website: www.sudairpharma.com
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