check - Bausch + Lomb

Reporter contact information/Initials*

Reporter Phone

Reporter e-mail address*

Province*

Reporter’s Profession*

Country of purchase*

USAMexicoCanadaOther

Other Country

Consent to Follow-up*

YesNo

Product/Drug name*

Dosage/Route/Frequency

Therapy Start date

Lot#

Product Expiry date

Reason for use of B+L product*

Patient Initials*

Date of birth

Height/Weight of Patient

Patient age group*

Please select from below option

Gender*

FemaleMaleNon-binaryPrefer not to say

Ethnic Origin

Pregnancy at time of reaction/event/side effect

YesNoN/A

Has the patient contacted their HCP about the Adverse Event

YesNo

Does the patient give consent to contact their HCP if required.

Did the reaction/Product issue/Adverse event Occur in Canada

YesNo

Please describe the Adverse reaction/Side effect/Product complaint*

Please describe Concomitant Medication (Include medications taken within 30 days before Adverse Reaction onset. Do not include medications taken as a treatment for the Adverse Reaction)

Please provide Relevant Tests/Laboratory Data (including dates) (yyyy-mm-dd)

Please provide Other Relevant History, Including Pre-existing Medical Conditions (e.g., allergies, pregnancy, smoking etc.)

Date signed *