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 ThromboGenics 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.

ThromboGenics 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 ThromboGenics 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 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

Personal details:

Your date of birth
Your date of birth

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

Date you were treated with JETREA
Date you were treated with JETREA
When did the event start?
When did the event start?
When was is resolved
When was it resolved?

If yes please provide following details:

Date of last menstrual period
Date of last menstrual period
Pregnancy onset date
Pregnancy onset date
Estimated date of delivery
Estimated date of delivery

Other Product

Other drugs
From
From
Untill
Until
Other drugs
From
From
Untill
Until
Other drugs
From
From
Untill
Until

Your physician

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