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Report Undesirable Effect

If you have encountered any side effect(s) to a CSL Behring product, we encourage you to talk to your doctor, pharmacist, or nurse.

CSL Behring also collects information about undesirable effects in order to monitor product safety and investigate, evaluate and report undesirable effects to appropriate regulatory bodies.

If you would like to report the side effect(s) to CSL Behring, please provide the following information to ensure your report of an undesirable affect is handled in a manner consistent with the applicable local laws. CSL Behring may contact you for further information about the undesirable effect.

CSL BEHRING PRODUCT INFORMATION
Product name
Reason for taking the product
(indication of use)
Start date of product
End date of product
Lot number(s) associated with the effect
SIDE EFFECT DETAILS
Start date of side effect
End date of side effect
Description of side effect(s),
including any necessary treatment
Personal data provided within this form
may be disclosed to a third party, such as
a Health Authority if we are required to do
so because of an applicable law, court order
or governmental regulation.
PATIENT DETAILS (person with the side effects)
Patient initials (first/last)
Age of patient
Gender
YOUR INFORMATION
Your name (optional)
Your relationship to the patient
Your country of residence:
Your contact–phone or email (optional)
Thank you for choosing to report an undesirable effect.
Please enter the verification code *
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