Side effect report form


1. Reporter information


Are you a Health Care Professional?
 
 
Country of residence
*
Please enter the country
*

2. Information about the person who experienced the side effect


Who experienced the side effects
 
 
Gender
 
Country of residence
 
Please enter the country
 

3. Information about the medicine


Add all Novo Nordisk suspect products
Please list the Novo Nordisk product(s) which you suspect could have caused the side effect(s). You can add more than one suspect Novo Nordisk product, if needed. Simply click 'add suspect product'.

4. Side effect description


Add all side effects
Please list the side effect(s) which you would like to report. You can report more than one side effect, if needed. Simply click 'add side effect'.

5. Consent and data privacy


Notice of personal data processing
*
May Novo Nordisk contact you for further information, if needed?
*
May Novo Nordisk contact your doctor for further information, if needed?