Adverse Event Report

Dear Sir or Madam,

At this point we would like to give you the opportunity to report of an adverse event during a Foscan® injection. A detailed form you can download >>here. You can send the form to the e-mail address pv@biolitecpharma.com or to the fax number +49 3641 519 5334.

For a direct opportunity to contact us the contact form below is available for you. In any case we will get in touch with you as soon as possible.

Reporter details

Name*

Status (Position, Patient, Other)

University/Hospital*

Unit/Department

Address

ZIP/Postal code

City

Phone number

Email*

Fax number

Product name: Foscan®

Indication*

Dose

Date of Foscan® injection*

Batch number of Foscan®

Date of illumination

Treating center*

Country of treating center*

Treating physician*

Details of the adverse event

Start date

End date

Description (including signs, symptoms, treatment, relevant lab data)*

Patient details

Initials (given name/ surname)*

Age*

Gender*

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