Report Side Effect

In case of a medical emergency, please contact your local healthcare professional for further assistance.

At Gen-eye we take the safety of our patients and consumers very seriously. We know that side effects can happen but it is not always possible to predict who will get them. For this reason, it is vital for us to continuously monitor the safety of our products. By hearing about your experiences and others like you we are able to offer the best possible advice to those using Gen-eye products.

    Source

    Consequence

    Reporter Details

    Patient Information

    Do you provide consent for further follow-up by our pharmacovigilance department regarding adverse event information that may be required?

    Product Details

    Did event/s reappear after medication was reintroduced?

    Did event/s diminish after medication was stopped or reduced?

    Start Date of Use

    Stop Date (If Applicable)

    Expiry Date

    Manufactured Date

    Action Taken

    Adverse Event Details

    Adverse Event Start Date

    Adverse Event/s Stop Date (If Applicable)

    Outcome of Event

    Was Treatment Received

    Concomitant Medication

    Only answer below questions if Yes
    YesNo

    Date Started

    Stop Date (If Applicable)

    Other Relevant Information, if Applicable:

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