Side-effect reporting form

If you wish to advise Actelion of any side-effects 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 patients

The fields marked with a * are mandatory.

Reporter (Your) Details
Patient Details (person who experienced the adverse event)
Pharmaceutical product details
About the adverse event
Other questions
Validation