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Patient report

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

If you experience a suspected side effect with JETREA, we recommend you to report it to your physician or healthcare provider. You can also report it to Oxurion by sending the completed form provided below. You can also report other safety related events (use during pregnancy or lactation, overdose, treatment errors such as overdose, usage outside the conditions in the label). You will be asked to provide your physician contact details. With your authorization, we will contact your physician to obtain further details of the reported event.

Oxurion will only use the data you provide in the form to contact you and/or your physician and to comply with the applicable laws on the processing of 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 events 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.

* Denotes required field

Personal details:

Your date of birth *
Year
Month
Day

Your adverse events following the administration of JETREA (ocriplasmin) that you wish to report:

Date you were treated with JETREA
Year
Month
Day
maximum 1500 characters
When did the event start?
Year
Month
Day
When was is resolved
Year
Month
Day

If yes please provide following details:

Date of last menstrual period
Year
Month
Day
Pregnancy onset date
Year
Month
Day
Estimated date of delivery
Year
Month
Day

Other Product

Other drugs
maximum 100 characters
From
Year
Month
Day
Until
Year
Month
Day
Other drugs
maximum 100 characters
From
From
Year
Month
Day
Until
Year
Month
Day
Other drugs
maximum 100 characters
From
From
Year
Month
Day
Until
Year
Month
Day

Your physician

(*)
(*)
(*)
(*)
Fields containing physician information (*) are required if you authorize Oxurion to contact your physician.
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