Pharmacovigilance – Extendis Pharma

Adverse Reaction Report Form

Please complete this form to report any adverse reaction related to the use of our products. The information provided will be treated confidentially.

Patient Initials

Age

Genrer

Reaction Start Date

Brief Description of Symptoms

Reporter Name

Relationship to the Patient

Phone Number

Email Address

Medication Name

Dosage Used

Start Date

End Date (if applicable)

I authorize the use of the information provided in this form for the follow-up and safety assessment of the medication.

This form does not replace medical consultation. If symptoms persist or worsen, please seek medical attention immediately.