Report a side effect

We are committed to continuously improving the quality of our products. We need your help with quality control and improvement. We therefore ask you to provide us with as much detail as possible regarding any side effects you have observed with our products. We will then reply to you as soon as possible. Thank you very much.

Please complete the form in full.

Side Effects Reporting Form

Title

Frau

Herr

First name

Surname

mail address

Age

Street and house number

Postcode

City

Country / State

Phone

Fax

Preferred method of contact

Fax

E-Mail

Product information

Why was the product used?

Were any other products used or taken?

Nein

Participating doctor

Title of the doctor

Doctor's name

Side effects

How was the product used, and what side effects occurred?

Bitte beschreiben Sie den Ablauf möglichst genau.

What measures have been taken?

Who else was notified apart from the manufacturer?

Please enter the characters

Ihre personenbezogenen Daten werden ausschließlich zur Bearbeitung Ihrer Anfrage verwendet. Für weitere Informationen sehen Sie bitte in unserem Datenschutzhinweis nach.