HOME MEDICAL REQUESTS ADVERSE EVENT REPORTING Current Preliminary information Reporter/enquirer details Product information Adverse event information Vifor Pharma takes the safety of patients very seriously. Reporting an adverse event allows us to continuously monitor the safety of our products. To help us process your report quickly and effectively, fill out the form below with as much relevant information as possible to report an adverse event for a Vifor Pharma product. Data privacy In order to respond to your enquiry it is necessary to collect some personal information such as your name and contact details. If you have queries concerning personal data or data privacy, please see our data privacy policy. Preliminary information Local reference number Personal information Type of contact* Consumer/ Other Non-HCP Dentist Lawyer Nurse Other Health professional Patient Pharmacist Physician Physician assistant Specialization* Abdominal Surgery Adolescent Medicine Aerospace Medicine Allergy and Immunology Cardiovascular Diseases Cardiovascular Surgery Chemical Pathology Child Psychiatry Chiropractics Clinical Pathology Clinical Pharmacology Colon and Rectal Surgery Critical Care Medicine Dental Medicine Dermatology Dermatopathology Diabetes Diagnostic Laboratory Immunology Diagnostic Radiology Emergency Medicine Endocrinology Epidemiology Facial Plastic Surgery, Otolaryngology Forensic Pathology Gastroenterology General Practice General Preventive Medicine General Surgery Genetic Medicine Geriatrics Gynecological Oncology Head and Neck Surgery Hematology Hematology Oncology Hepatology Immunology Immunopathology Infectious Diseases Internal Medicine Legal Medicine Medical Microbiology Medical Oncology Neonatal-Perinatal Medicine Nephrology Neurological Surgery Neurology Neuropathology Neuropsychology Nuclear Medicine Nuclear Radiology Nutrition Obstetrics and Gynecology Occupational Medicine Oncology Oncology Nurse Oncology Nurse Coordinator Ophthalmology Orthopedic Surgery Osteopathy Other Otolaryngology Otorhinolaryncology (ENT) Pathology Pediatric Allergy Pediatric Cardiology Pediatric Endocrinology Pediatric Hematology-Oncology Pediatric Nephrology Pediatric Neurology Pediatric Pulmonology Pediatric Radiology Pediatric Surgery Pediatrics Physical Medicine and Rehabilitation Physiotherapist Plastic Surgery Psychiatry Psychoanalysis Public Health Pulmonary Diseases Radiation Oncology Radioisotopic Pathology Radiology Reproductive Endocrinology Rheumatology Thoracic Surgery Traumatic Surgery Urological Surgery Urology Vascular Surgery Vetinary Medicine Occupation* Consumer/ Other Non-HCP Dentist Family Doctor Investigator Lawyer Literature Author Medical Representative Nurse Other Health professional Patient Pharmacist Physician Scientist Sponsor *Mandatory field Reporter/enquirer details Personal information Contact information Address Country* United Kingdom Germany France Spain Italy Other Do you consent to Vifor Pharma contacting you with further information?* Yes No *Mandatory field Product information Product details Dose unit* American Hospital Formulary unit Arbitrary unit As necessary Becquerel(s) Cells Centigram Centilitre Copies per microgram Curie(s) Cyclical Decade Decigram Decilitre Dosage form Drop(s) Equivalent Femtogram Femtometre Femtomole Femtomole per gram Femtomole per milligram Gigabecquerel(s) Gram per kilogram per 8 hour Gram per 100 gram Gram per gram Gram per hour per square metre Gram per kilogram Gram per kilogram per minute Gram per square metre Gram(s) homeopathic potency of centesimal hahnemannian series homeopathic potency of centesimal korsakovian series Homeopathic potency of decimal hahnemannian series Homeopathic potency of decimal korsakovian series Homeopathic potency of millesimal hahnemannian series Homeopathic potency of millesimal korsakovian series Homeopathic potency of quintamillesimal hahnemannian series Homeopathic potency of quintamillesimal korsakovian series International unit per gram International unit per gram of hemoglobin International unit(s) Iu/kilogram Kilobecquerel(s) Kilogram per cubic metre Kilogram per square metre Kilogram(s) Kilo-international unit Litre per kilogram Litre(s) Megabecquerel(s) Mega-international unit Micro international unit Microcurie(s) Microequivalent Microgram per 100 gram Microgram per cubic metre Microgram per gram Microgram per kilogram per minute Microgram per milligram Microgram(s) Microgram(s)/ sq. Meter Microgram(s)/kilogram Microlitre(s) Micromole bone collagen equivalent per mole Micromole per gram Micromole per kilogram Micromole per milligram Micromole(s) Millicurie(s) Milliequivalent(s) Milligram per cubic metre Milligram per gram Milligram per hour Milligram per millilitre Milligram(s) Milligram(s)/kilogram Milligram(s)/sq. meter Milli-international unit Millilitre per hour Millilitre per kilogram Millilitre per square metre Millilitre(s) Millimole per gram Millimole per kilogram Millimole per square metre Millimole(s) Million international unit Million per kilogram Milliosmole Milliosmole per kilogram Milliosmole per litre Mole per cubic metre Mole per kilogram Mole(s) Nanocurie(s) Nanogram per gram Nanogram per kilogram Nanogram per milligram Nanogram per square metre Nanogram(s) Nanolitre Nanomole Nanomole per gram Percent Picogram per milligram Picogram(s) Picolitre Picomole Picomole per gram Total Trimester Units min hours Route of administration* Auricular (otic) Buccal Conjunctival Cutaneous Dental Electro-osmosis Endocervical Endosinusial Endotracheal Enteral Epidural Extra-amniotic Gastroenteral Gingival Hemodialysis Implantation In drinking water In vitro Infiltration Interstitial Intra corpus cavernosum Intra-abdominal Intra-amniotic Intra-arterial Intra-articular Intrabiliary Intrabronchial Intrabursal Intracardiac Intracardial Intracartilaginous Intracaudal Intracavernous Intracavitary Intracavity Intracerebral Intracervical Intracisternal Intracorneal Intracoronal (dental) Intracoronary Intradermal Intradiscal (intraspinal) Intraductal Intraduodenal Intradural Intra-epidermal Intra-esophageal Intragastric Intrahepatic Intra-ileal Intralesional Intralymphatic Intralyphatic Intramedullar (bone marrow) Intrameningeal Intramuscular Intra-muscular Intramuscular and Intravenous Intraocular Intra-ovarian Intrapericardial Intraperitendineal Intraperitoneal Intrapleural Intraprostatic Intrapulmonary Intrasinal Intrasternal Intrasynovial Intratendinous Intratesticular Intrathecal Intrathoracic Intratracheal Intra-tracheal Intratubular Intratumor Intratympanic Intra-uterine Intravascular Intravenous Intravenous (not otherwise specified) Intravenous bolus Intravenous drip Intraventricular Intravesical Intravitreal Iontophoresis Irrigation Laryngeal Laryngopharyngeal Nasal Nasal J-tube NASOGASTRIC Not applicable Occlusive dressing technique Ocular use Ophthalmic Oral Oral and Intramuscular Oral and Intravenous Oromucosal Oropharyngeal Other Parenteral Per oral Per rectal Per semen Percutaneous Periarticular Peridural Perineural Periodontal Rectal Respiratory (inhalation) Retrobulbar Soft tissue Subarachnoidal Subconjunctival Subcutaneous Sublingual Submucosal Topical Transdermal Transmammary Transmucosal Transplacental Transtracheal Transtympanic Unknown Ureteral Urethral Vaginal *Mandatory field Adverse event information Adverse event or special situation Please provide the adverse event term in your local language. You may report up to six adverse events. Please include one term per field. Adverse event terms Adverse event terms Narrative Describe the event and provide any relevant additional information that you wish to include in your local language. Case seriousness Assessment should always be done by a health care professional. Case seriousness* Serious Non-Serious Patient details Gender* Female (F) Male (M) Unknown Unspecified If known, please provide the patient's date of birth only, if unknown, you may provide either the patient's age or age group. Age group Neonate Foetus Infant Child <18 Adult 18-65 Elderly >65 Adolescent Pregnancy status Yes No Unknown Trimester status Trimester 1 Trimester 2 Trimester 3 Trimester 1-2 Trimester 2-3 Trimester 1-3 Patient consent for contact* Yes No Not Applicable Additional comments Data privacy In order to respond to your enquiry it is necessary to collect some personal information such as your name and contact details. If you have queries concerning personal data or data privacy, please see our data privacy policy Have you informed the reporter/enquirer about Data Privacy Notice? Yes No CAPTCHA Math question 13 + 5 = Solve this simple math problem and enter the result. E.g. for 1+3, enter 4. *Mandatory field Data privacy The personal data provided on this form will be stored and used by Vifor Pharma Management Ltd., Flughofstrasse 61, 8152 Glattbrugg, Switzerland and/or its affiliates (“Vifor Pharma”) and their service providers and collaboration partners to process the unsolicited request for medical information and respond to it. After responding to the request, they could use the content of the unsolicited request and the response to it for medical information purposes on an anonymized basis. If the enquiry contains safety information, Vifor Pharma is required by law to forward it to its drug safety department for processing and reporting to health authorities. That department will receive the reporter details to document the source and for follow-up purposes. If you would like to receive a copy of our Privacy Notice please send an e-mail to: groupdpo@viforpharma.com. Authorisation I hereby certify that this is an unsolicited request, initiated by myself and completely independent of Vifor Pharma Group, and that I am a healthcare professional licensed to prescribe, purchase, supply, recommend or administer medicinal products.