Report a side effect · Paramount Pharmaceuticals

Step 1 of 5/About you

About 4 min left

Who is reporting?

Patient / family memberDoctorPharmacistNurse / other HCP

Your name

PhoneOptional

So our medical team can follow up quickly.

CityOptional

Patient initials

Initials only, e.g. A.K.

AgeOptional

Weight (kg)Optional

SexOptional

FemaleMalePrefer not to say

Paramount medicine

Pick from the list, or type what’s on the pack.

Batch / lot numberOptional

Printed on the pack, e.g. B.No. 26K014

Dose & frequencyOptional

Started taking itOptional

Reason for taking itOptional

Other medicines taken at the same timeOptional

Report a side effect.