Adverse Event Reporting

If you wish to notify us of an adverse event by drugs produced by Acium, please fill in and submit the form below.

Contact Details of Reporter:

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Telephone

Patient Details:

First Name

Last Name

Gender (at Birth):

Age

Product code

Product description: Name, Form, Strength

Batch number

Expiry date

Quantity of the product involved

Description of Incident (Please be as specific as possible and include the site of the adverse reaction e.g. lower limb, lungs, right arm)

Date of incident

Adverse events should be reported. We monitor the safety of all our products and encourage the reporting of adverse events.
Reporting forms and information can also be found at yellowcard.mhra.gov.uk.