Idorsia Adverse Event Reporting Form

We strongly encourage you to report any possible ADVERSE EVENT OR SIDE EFFECT due to one of our products. Please report your ADVERSE EVENT OR SIDE EFFECT using the following form.

If this is an emergency, please contact your local health care physician immediately.

Adverse Event/Side Effect Information:

Please enable JavaScript in your browser to complete this form.
Describe the adverse event/side effect providing details on treatment needed and medical history, if any.
The date of the start of the reaction/event or date of the first symptom.
The date the reaction/event was reported as resolved/recovered
Life Threatening
Congenital Anomaly/Birth Defect
Results in Death
Other Medically Important Condition
Caused/Prolonged Hospitalization
Please provide the latest outcome of the adverse event or side effect you experienced.

Patient Information:

The identification of the patient may be prohibited by certain national confidentiality laws or directives. The information should be provided when it is in conformance with the confidentiality requirements
The sex of the patient
The age at the time of the first reaction/event (number only)
A full precision date should be used (i.e., day, month, year). If the full date of birth is unknown, an approximate age can be used
When providing the age in decades,please note that, for example, the 7th decade refers to a person in their 60’s

Product Information:

Select the reported product
This is particularly important for vaccines and biologicals. The section allows for multiple batch or lot numbers, each separated by a delimiter defined by the transmission standard chosen. The most specific information available should be provided.
Example: 5 mg 2 times a day every other day for 30 days
First date of use
For ongoing drug administration after the onset of the reaction or event, this item should be blank and Actions taken with drug should be used.
These data, taken together with the outcome of the reaction, provide the information concerning dechallenge. "Not applicable" should be used in circumstances such as if the patient died or the treatment had been completed prior to the reaction or event.

Reporter Information

Captures whether the reporter has consented to being contacted in relation to this report.

Idorsia retains your personal data to address or provide a reply to your medical information inquiry. In processing your personal data, Idorsia will fully comply with internationally recognized standards of data protection. In doing so, Idorsia ensures compliance of its staff with strict standards of security and confidentiality. Additional information on the processing of personal data and the exercise of rights related to your personal data can be found in Idorsia’s Privacy Policy