Adverse event reporting form

If you wish to advise Actelion of any adverse event or adverse drug reaction that takes place, please do not hesitate to use this form.

An adverse event is defined as any untoward medical occurrence in a patient or clinical investigation subject administered a pharmaceutical product. This untoward medical occurrence does not necessarily imply a causal relationship with the particular treatment and includes the following:

  • Lack of efficacy
  • Suspected transmission of an infectious agent via a product
  • Overdose, misuse or medication errors
  • Pregnancy/lactation when using a product (whether or not associated with an adverse event)
  • Drug-drug interactions

Form for Healthcare Professionals

The fields marked with a * are mandatory. All submitted forms will be reviewed by Global Drug Safety at Actelion. Please be aware that they may contact you for further information.

Reporter (Your) Details
Patient Details
Suspected drug(s)
Other medicines
Event details
Other information
Validation