Pharmacosmos Therapeutics Adverse Event Form
By reporting potential side effects to our products, the information you provide will help us fulfill our responsibility to report to the FDA and our responsibility to ensure the safety of our products.
Reporter's Name
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First Name
Last Name
Reporter's Job Title
Reporter's phone number or email address for follow-up
*
A member of our Pharmacovigelence team may follow-up to further discuss this report. If applicable click below.
I would not like to be contacted by the PTI Pharmacovigilance team for further follow-up with this report
Reporter's Site/Facility Name
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Reporter's Site/Facility Zip Code
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Patient's Initials
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Type unknown if unavailable
Name of PTI Product Used
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Please Select
Monoferric
Cosela
Date and Time Reaction Occurred
*
Type unknown if unavailable
Other Patient Characteristics (DOB, Sex, Height, Weight, Race, etc.)f
*
Type unknown if unavailable
Patient's Medical History (Diagnosis, Comorbidities, Pre and Post Vitals, Pregnancy Status, etc.)
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Type unknown if unavailable
Please provide description of the adverse reaction you are reporting. Include patient outcome if available.
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Submit
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