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?

Complete the form below to report a safety related event in a patient who has been treated with JETREA.
These safety related events can include:

  • adverse events
  • use during pregnancy or lactation
  • suspected interaction with other products
  • treatment errors, such as an overdose
  • any side effects that aren't listed on the label of the product

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

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

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

If your country is not listed here, please contact the local representative of Oxurion 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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