Report Side Effects to LEO Pharma

Please fill in the fields as accurate as possible. It there are fields you cannot fill in, please write "unknown". Fields marked with must be filled in.

Please use the date format DD-MMM-YYYY (Example 25-FEB-2014). If you do not know the exact date, please state as close as possible (Example NOV-2014).

If you have further relevant information, please use the field 'Additional information'

NB: The products Burinex®, Centyl® K, Condyline®, Conotrane®, Fonx®, Kaleorid®, Locobase®, Mildison®, Selexid® and Synalar® have been sold to Karo Pharma A/S on April 4, 2018. LEO Pharma will therefore transfer side effects, which will be received for these products to Karo Pharma A/S.

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Reporting side effects on LEO Pharma products

PATIENT INFORMATION
Patient's initials (only state the first letter in the first name and surname and not the full name): 
Gender*:
 
Pregnant?
 
Age at the time of the side effect:  
Weight: 
Are you the patient?
 
DRUG INFORMATION
Name of LEO Pharma drug used: 
Lot/batch no. of LEO Pharma drug (if available): 
Name of the disease for which this LEO Pharma drug was used: 
First date of treatment with the LEO Pharma drug: 
Daily dose of the LEO Pharma drug: 
Has treatment with the LEO Pharma drug been stopped?
 
If yes on which date did the treatment stop? 
SIDE EFFECT INFORMATION
List the side effect(s) experienced by the patient?  
At what date did the side effect(s) start? 
Describe what happened (how did the side effect(s) start, 
Has the patient suffered from the same side effect(s) previously?
 
If yes, please specify which drug(s) was taken at the time: 
What is the current outcome of the side effects(s)?
 
 
 
Did the side effect(s) following use of the LEO Pharma drug lead to any of the following?
 
 
 
 
 
If the side effect(s) following use of the LEO Pharma drug lead to death of the patient, please specify the date in which the patient died  
OTHER DRUG INFORMATION
Were other drugs taken at the same time as the side effect(s) occurred?
 
If yes, please list the following information:
a) The name of the drug(s): 
b) The disease(s) for which the drug(s) was taken: 
c) The start date: 
DISEASE INFORMATION
At the time of the side effect to the LEO drug, was the patient suffering from any other disease, including allergies?
 
If yes please describe the following:
a) Disease: 
b) Date started: 
c) Treatment prescribed: 
ADDITIONAL INFORMATION
Please use this field for any additional information you would like to provide:  
REPORTER INFORMATION
Your name: 
Country: 
Are you a Health Care Professional?
 
If yes, please specify type (doctor, pharmacist nurse):  
e-mail address (a copy of the form will be sent to this e-mail): 
Please press the 'send' button in order for LEO Pharma to receive your side effect report

Report side effects by email

If you experience any side effects, please talk to your doctor, pharmacist or nurse. If you wish to report side effects regarding a LEO Pharma product via email or phone, please email: medical-info.uk@leo-pharma.com or telephone: +44 (0) 1844 347 333 and press 2 for Medical Information.

You can also report side effects directly via the national reporting system.         

For the United Kingdom, via the Yellow Card Scheme, Website: www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.

For Ireland, via HPRA Pharmacovigilance E-mail: medsafety@hpra.ie

LEO Pharma are required to record all relevant data to ensure the safety of our products. You can find more information about which data we record, your rights and how data privacy is ensured etc. on www.leo-pharma.co.uk/Home/Terms-of-use/Pharmacovigilance-Notice.aspx and www.leo-pharma.com. If you have any questions please contact us via email at medical-info.uk@leo-pharma.com or by telephone at +44 (0) 1844 347 333 and press 2 for Medical Information.

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