Medical services form test page You must have JavaScript enabled to use this form. If you wish to report adverse reactions related to the use of Bracco drugs, complaint related to a Bracco product or an unwanted incident related to the use of Bracco medical devices we kindly ask you to fill this form below or contact us by phone at +46 31 760 18 80. Last name Email Phone Please select type of inquiry and fill the following information Adverse Drug Reaction Product Complaints Incidents with Medical Devices Reaction description An identifiable patient (with at least any of the following information: Gender, Age, Date of Birth or Initials): An identifiable reporting source (reporter): An event (an undesirable effect): The name of the suspected Bracco product and batch number: Product description The name of the product and batch number, if available: A description of the complaint: The reporting source (medical doctor, hospital etc.): Incident description Date when the incident occurred: Information about the hospital/healthcare facility where the incident occurred: Information about the reporter: Information about the patient: A description of the event: Indication/use of the medical device: Outcome: Product information including batch number:
Medical services form test page You must have JavaScript enabled to use this form. If you wish to report adverse reactions related to the use of Bracco drugs, complaint related to a Bracco product or an unwanted incident related to the use of Bracco medical devices we kindly ask you to fill this form below or contact us by phone at +46 31 760 18 80. Last name Email Phone Please select type of inquiry and fill the following information Adverse Drug Reaction Product Complaints Incidents with Medical Devices Reaction description An identifiable patient (with at least any of the following information: Gender, Age, Date of Birth or Initials): An identifiable reporting source (reporter): An event (an undesirable effect): The name of the suspected Bracco product and batch number: Product description The name of the product and batch number, if available: A description of the complaint: The reporting source (medical doctor, hospital etc.): Incident description Date when the incident occurred: Information about the hospital/healthcare facility where the incident occurred: Information about the reporter: Information about the patient: A description of the event: Indication/use of the medical device: Outcome: Product information including batch number: