Form For Healthcare Professionals

All information and personal data you share with us via e-mail will be protected and kept confidential in accordance with Bluefish's processes and applicable regulations in the world, Europe and Sweden. Any information that you assist us with will be used to monitor drug safety and to be able to evaluate the risk/benefit balance. Personal data may be shared with pharmaceutical authorities within the EU and within the Bluefish organization. You have the right to access the personal data we have about you.

An asterisk (*) indicates that the field is mandatory and must be filled in.

Your first name *

Your surname *

Occupation

Phone number *

E-mail *

Patient initials

Date of birth or age *

Sex at birth *

Name and strength of the medicinal product *

Dosage

Batch number

Describe the suspected adverse event *

Primary disease

Form For Healthcare Professionals

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