Delivering next-generation treatments for back of the eye disorders, with focus on diabetic eye disease

Healthcare professional report

How to report  a suspected side effect (adverse event)  with the use of Jetrea?

If you wish to report to ThromboGenics a safety related event (adverse event,  use during pregnancy or lactation, suspected interaction with other products, treatment errors such as overdose, usage outside the conditions in the label)  in a patient treated with JETREA,  please complete the  form provided below. 

ThromboGenics will only use the data you provide in the form to contact you and to comply with the applicable laws on this type of information.  By completing your details you agree that ThromboGenics may use the information that you have submitted for the purposes of: 

  • contacting you for more information on the suspected adverse event you have reported 
  • disclosing information to Government healthcare agencies as required by law 

 

You also agree that ThromboGenics may transfer, store and process the information outside your country (including outside of the USA) as required by other countries laws.

* Denotes required field

If your country is not listed here, please contact the local representative of ThromboGenics indicated in the product label.

Product

Treatment date with JETREA
Treatment date with JETREA
Year
Month
Day

Other suspect treatment? Add suspect treatment and treatment date.

Other treatment
Suspect treatment date
Treatment date
Year
Month
Day
Other treatment
Suspect treatment date
Treatment date
Year
Month
Day
Othertreatment
Othertreatment date
Treatment date
Year
Month
Day

Type of report*

Please select ‘Adverse event’ or ‘Suspected exposure to JETREA during pregnancy/in utero' or both

Onset date
Onset date
Year
Month
Day

Your Contact details

eg. John
eg: Smith
maximum 1000 characters

Your telephone number

(eg. 20 7536 4256)

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