Adverse Event Reporting

Name of Ytiliga Drug *

Nature of event (Check all that apply) * Adverse Event/Side Effect Pregnancy/lactation Overdose Lack of efficacy Misuse Abuse Product Complaint

Patient Information

Name or Initials *

Sex * Male Female

Age / Age Group

Event Description

Description of Adverse Event / Side Effect / Any other experience such as Lack of Effect, Medication Error *

Current Status / Outcome: (at the time of this report) * Complete Recovery Ongoing Recovering Unknown Died Others (pls specify)

Drug Use Detail

Suspect Drug details *

Indication *

Dosage / Unit / Frequency *

Route *

Suspect Drug details *

Indication *

Dosage / Unit / Frequency *

Route *

Treatment Dates

Start Date

Month

Day

Year

End Date

Month

Day

Year

Lot/Batch # *

Expiry Date

Month

Day

Year

Relevant Medical History (If Available)

Reporter Information

Full Name *

Street Address

City *

ZIP / Postal Code *

Country

Email *

Phone *

Are you also the patient * Yes No

Relationship with Patient

I accept that all enquiries submitted to "Adverse Event Reporting" are sent to Ytiliga global pharmacovigilance team, headquartered in India. I accept that my personal data are shared with the relevant local team. I accept the Ytiliga general Privacy Policy, described here