COMPANY
ACCREDITATION
CAREERS
EXECUTIVES
DIGITAL BROCHURE
PRINCIPLES
WHO WE ARE
CONTACT
HEALTH CONNECT
ADHERENCE
ADVERSE EVENT REPORTING
ONE EXPRESS
MY CARE
PATIENTS
ASK YOUR PHARMACIST
FAQ
HEALTH CONNECT
RX ASSIST
MY CARE
PATIENT SURVEY
PATIENT RESOURCES
PRESCRIBERS
FAQ
ONE EXPRESS
RX ASSIST
HEALTH CONNECT
MY CARE
PHARMACY INFORMATION
PROGRAMS
ASSISTANCE PROGRAM
ONE EXPRESS
ADVERSE EVENT REPORTING
HEALTH CONNECT
RX ASSIST
MY CARE
SERVICES
ADHERENCE
ASSISTANCE PROGRAM
CUSTOMIZED MEDICATION PACKAGING
IMMUNIZATION
INSURANCE
MENTAL HEALTH
MY CARE
ORPHAN THERAPIES
ONE EXPRESS
OTC MEDICATION
PET MEDICATION
PERSONALIZED MEDICATION MANAGEMENT
PRESCRIPTION BUNDLE PROGRAM
RX ASSIST
SMOKING CESSATION
SPECIAL AUTHORIZATION
STRESS MANAGEMENT
SPECIALTIES
FERTILITY
HEPATITIS
HIV
GASTROENTEROLOGY
DERMATOLOGY
MULTIPLE SCLEROSIS
ONCOLOGY
OPHTHALMOLOGY
RHEUMATOLOGY
RARE DISEASE
ASTHMA
CARDIOLOGY
Menu
COMPANY
ACCREDITATION
CAREERS
EXECUTIVES
DIGITAL BROCHURE
PRINCIPLES
WHO WE ARE
CONTACT
HEALTH CONNECT
ADHERENCE
ADVERSE EVENT REPORTING
ONE EXPRESS
MY CARE
PATIENTS
ASK YOUR PHARMACIST
FAQ
HEALTH CONNECT
RX ASSIST
MY CARE
PATIENT SURVEY
PATIENT RESOURCES
PRESCRIBERS
FAQ
ONE EXPRESS
RX ASSIST
HEALTH CONNECT
MY CARE
PHARMACY INFORMATION
PROGRAMS
ASSISTANCE PROGRAM
ONE EXPRESS
ADVERSE EVENT REPORTING
HEALTH CONNECT
RX ASSIST
MY CARE
SERVICES
ADHERENCE
ASSISTANCE PROGRAM
CUSTOMIZED MEDICATION PACKAGING
IMMUNIZATION
INSURANCE
MENTAL HEALTH
MY CARE
ORPHAN THERAPIES
ONE EXPRESS
OTC MEDICATION
PET MEDICATION
PERSONALIZED MEDICATION MANAGEMENT
PRESCRIPTION BUNDLE PROGRAM
RX ASSIST
SMOKING CESSATION
SPECIAL AUTHORIZATION
STRESS MANAGEMENT
SPECIALTIES
FERTILITY
HEPATITIS
HIV
GASTROENTEROLOGY
DERMATOLOGY
MULTIPLE SCLEROSIS
ONCOLOGY
OPHTHALMOLOGY
RHEUMATOLOGY
RARE DISEASE
ASTHMA
CARDIOLOGY
1.855.
MYCARE
.8
ADVERSE EVENT REPORTING
Web Site
Your Name:
Date of Birth
Province
- Select Province/State -
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Nova Scotia
Northwest Territories
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
====================
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Age (Years)
Sex
Man
Woman
N/A
Reaction Onset
Description of the Event
Check All Appropriate to Adverse Reaction
Patient Died
Involved or prolonged patient hospitalization
Involved persistent or significant disability or incapacity
Life threatening
Suspected Drug(s) (Include generic name)
Daily dose(s)
Route(s) of administration
Indication(s) for use
Therapy date start
Did reaction abate after stopping the drug(s)?
Yes
No
N/A
Therapy duration
Did reaction reappear after reintroduction?
Yes
No
N/A
Concomitant drug(s) and dates of administration (exclude those used to treat reaction)
Other relevant history (e.g. diagnostics, allergies, pregnancy with last month of period, etc.)
Name and address of manufacturer
Production date
MFR control number
Expiration date
Report Source
Study
Literature
Health professional
Report Type
Initial
Follow Up
N/A
