Report Side Effect - Actor Speciality

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In case of a medical emergency, please contact your local healthcare professional for further assistance.

At Actor Speciality we take the safety of our patients and consumers very seriously. We know that side effects can happen but it is not always possible to predict who will get them. For this reason, it is vital for us to continuously monitor the safety of our products. By hearing about your experiences and others like you we are able to offer the best possible advice to those using Actor Speciality products.

Adverse Effect

First Name

Last Name

Email

Subject

Your Message

Source

Consequence

Reporter Details:

Name of Reporter

Landline Contact Number

Mobile Number

Email

City

Patient Information:

Name/Initials of Patient

Gender

Male

Female

Age of Patient

Date of Birth

Do you provide consent for further follow-up by our pharmacovigilance department regarding adverse event information that may be required?

Yes

No

Product Details:

Product Name on Dosage Form

Dosage Frequency

Route of Administration

Indication/Use

Did event/s reappear after medication was reintroduced?

Yes

No

Not Applicable

Unknown

Did event/s diminish after medication was stopped or reduced?

Yes

No

Not Applicable

Unknown

Start Date of Use

Stop Date (If Applicable)

Batch Number

Lot Number

Expiry Date

Manufactured Date

Action Taken

Dose Unchanged

Permanently Withdrawn

Temporarily Withdrawn

Not Applicable

Unknown

Adverse Event Details:

Describe Adverse Event

Adverse Event/s Start Date

Adverse Event/s Stop Date

Outcome of Event

Recovered

Not Recovered

Recovering

Unknown

Was Treatment Received

Yes

No

Unknown

Not Applicable

Concomitant Medication:

Only Answer Below Question if Yes

Yes

No

Trade Name & Batch Number (Asterisk Suspected Product)

Route

Daily Dosage/Frequency

Date Concomitant Medication Started

Date Concomitant Medication Stopped (If Applicable)

Indication

Other Relevant Information, If Applicable

Additional Information

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