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

    In processing your personal data, Actelion will fully comply with internationally recognized standards of data protection. In doing so, Actelion ensures compliance of its staff with strict standards of security and confidentiality.