Adverse Event & Product Complaint Reporting form

If you are reporting a product complaint please retain the complaint sample in the same storage conditions for further investigations.

Alternatively to report an adverse event, you can call us on +(971) 5444-09415

Adverse event/ Product Complaint Received Date

Please enter the date you were aware of the adverse event or product complaint (date format: DD/MM/RRRR)

Adverse event/ Product Complaint Occurance Date

When did the adverse event or product complaint occur? (date format: DD/MM/RRRR)

Reporter's Name

Consent to Follow up Yes No Unknown

Reporter's Contact details (Email/Phone number)

Patient information (Initials, Sex, Age, Height in cm , Weight in kg)

Product Name (Brand/Generic name)

Product Indication and Dose

Product Batch Number

2000 characters left

Description of Adverse event or Product Compliant

2000 characters left

Additional Information

Roche Employee/ Service provider Name

Secondary Reporter (if applicable)

*Disclaimer: By submitting this form you are aware that Roche has legal obligation to collect and report potential adverse events brought to its attention to Health Authorities. In such cases, your data will be processed with greatest care and diligence in accordance with specific GVP (pharmacovigilance) legislation, as described in the Privacy Policy related to pharmacovigilance [https://www.roche.com/privacy-notice-pv-mi.htm]. Your data will not be used for any other purpose.