To report a side effect or other safety information to Lundbeck, please fill in the form below. In the form, whenever the term "side effect" is used, information on other safety information can also be provided.
Fields marked with * must be filled in. Do not provide personal information such as full name, address or social security/personal identity number when filling out the form.
In the form, you will be provided with the opportunity to fill in information on who is reporting the side effect or other safety information, the patient and type of Lundbeck medication involved, as well as details on the side effect. Information on any additional medications taken or conditions had by the patient can also be provided.
All information reported to Lundbeck will be assessed by a patient safety employee. In some cases, Lundbeck might assess that it would be beneficial to get further information to evaluate the side effect. Providing consent for Lundbeck to contact you is fully optional.
Can Lundbeck contact you using the information from this form if necessary? *
Please let us know your contact preference *
Who is reporting the side effect?
Are you the patient experiencing a side effect? *
Relationship with the patient
Please describe how you learned about the side effect
In which country did the side effect(s) occur? * Â
---Choose location--- Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Saint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Canary Islands Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d Ivoire Croatia Cuba Curacao Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran (Islamic Republic of) Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, Democratic Peoples Republic of Korea, Republic of Kosovo Kuwait Kyrgyzstan Lao Peoples Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia (Federated States of) Moldova, Republic of Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin (FR) Saint Pierre and Miquelon Saint Vincent and the Grenadines Saint-Barthélemy Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (NL) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Island South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Islands Swaziland Sweden Switzerland Syrian Arab Republic Taiwan, Republic of China Tajikistan Tanzania, United Republic of Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City State (Holy See) Venezuela Viet Nam Virgin Islands (British) Virgin Islands (U.S) Wallis and Futuna Islands Western Sahara Yemen Zaire Zambia Zimbabwe
Was the Lundbeck medication purchased in the country where the side effect(s) occurred?
In which country was the Lundbeck medication purchased?
---Choose location--- Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Saint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Canary Islands Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d Ivoire Croatia Cuba Curacao Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran (Islamic Republic of) Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, Democratic Peoples Republic of Korea, Republic of Kosovo Kuwait Kyrgyzstan Lao Peoples Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia (Federated States of) Moldova, Republic of Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin (FR) Saint Pierre and Miquelon Saint Vincent and the Grenadines Saint-Barthélemy Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (NL) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Island South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Islands Swaziland Sweden Switzerland Syrian Arab Republic Taiwan, Republic of China Tajikistan Tanzania, United Republic of Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City State (Holy See) Venezuela Viet Nam Virgin Islands (British) Virgin Islands (U.S) Wallis and Futuna Islands Western Sahara Yemen Zaire Zambia Zimbabwe
Who experienced the side effect?
Was or is the patient pregnant while being treated with Lundbeck medication? * Â
Please add any information available on the outcome or current status of the pregnancy
Which Lundbeck medication was the patient treated with?
Please add one medication at a time. You will have the option to fill in information for more at the bottom of the page.
What is the name of the Lundbeck medication suspected to cause the side effect? *
---Choose one--- Abilify Abilify Maintena Abixa Azilect Brintellix Carnexiv Celexa Ciatyl-Z Cipralex Cipram Cipramil Cisordinol Clopixol Cosmegen Deanxit Depixol Ebix Ebixa Elopram Entact Escitalopram Esertia Esipram Fluanxol Fonksera Frisium Indacin I.V Lepax Lexapro Memantine Merz Modiodal Noritren Northera Nortrilen Nuvigil Onfi Premalex Prilect Prisdal Redomex Rexulti Sabril Saroten Sarotena Sarotex Selincro Sensaval Sepram Serdolect Seroplex Seropram Sipralexa Trintellix Truxal Vortioson Vurtuoso Vyepti Xenazine Other (please specify)
Please provide the indication (reason for prescription) of the Lundbeck medication
How often was/is the Lundbeck medication taken or administered?
Is treatment with the medication ongoing?
Is/was the patient treated with more than one type of Lundbeck medication?
Other Lundbeck drug
Name of the Lundbeck medication
---Choose one--- Abilify Abilify Maintena Abixa Azilect Brintellix Carnexiv Celexa Ciatyl-Z Cipralex Cipram Cipramil Cisordinol Clopixol Cosmegen Deanxit Depixol Ebix Ebixa Elopram Entact Escitalopram Esertia Esipram Fluanxol Fonksera Frisium Indacin I.V Lepax Lexapro Memantine Merz Modiodal Noritren Northera Nortrilen Nuvigil Onfi Premalex Prilect Prisdal Redomex Rexulti Sabril Saroten Sarotena Sarotex Selincro Sensaval Sepram Serdolect Seroplex Seropram Sipralexa Trintellix Truxal Vortioson Vurtuoso Vyepti Xenazine Other (please specify)
Please provide the indication (reason for prescription) of the Lundbeck medication
How often was/is the Lundbeck medication taken or administered?
Is treatment with the medication ongoing?
Name of the Lundbeck medication
---Choose one--- Abilify Abilify Maintena Abixa Azilect Brintellix Carnexiv Celexa Ciatyl-Z Cipralex Cipram Cipramil Cisordinol Clopixol Cosmegen Deanxit Depixol Ebix Ebixa Elopram Entact Escitalopram Esertia Esipram Fluanxol Fonksera Frisium Indacin I.V Lepax Lexapro Memantine Merz Modiodal Noritren Northera Nortrilen Nuvigil Onfi Premalex Prilect Prisdal Redomex Rexulti Sabril Saroten Sarotena Sarotex Selincro Sensaval Sepram Serdolect Seroplex Seropram Sipralexa Trintellix Truxal Vortioson Vurtuoso Vyepti Xenazine Other (please specify)
Please provide the indication (reason for prescription) of the Lundbeck medication
How often was/is the Lundbeck medication taken or administered?
Is treatment with the medication ongoing?
What side effect did the patient experience?
Please add one side effect or description of other safety information at a time. You will have the option to fill in information for more at the bottom of the page.
Please describe the experienced side effect *
What is the status of the side effect?
Did more than one side effect occur?
Please describe the experienced side effect
What is the status of the side effect now?
Please describe the experienced side effect
What is the status of the side effect now?
Please describe the experienced side effect
What is the status of the side effect now?
As a result of any side effect did the patient:
Was the patient taking any other type of medication?
Would you like to report any other medications the patient was taking when the side effect occurred?
Please add one medication at a time. You will have the option to fill in information for more at the bottom of the page.
Please provide the name of additional medication taken by the patient when the side effect occurred
Please provide the indication (reason for prescription) of the medication
Is treatment with the medication ongoing?
Was the patient treated with additional/other medication when the side effect occurred?
Additional other drugs
Please provide the name of additional medication taken by the patient when the side effect occurred
Please provide the indication (reason for prescription) of the medication
Is treatment with the medication ongoing?
Please provide the name of additional medication taken by the patient when the side effect occurred
Please provide the indication (reason for prescription) of the medication
Is treatment with the medication ongoing?
Did the patient have any other disease(s) or condition(s)?
Would you like to report any other disease/conditions at the time the side effect occurred?
Please add one disease/condition at a time. You will have the option to fill in information for more at the bottom of the page.
Status or development of the disease/condition
Was any treatment given for the disease/condition?
If treatment was provided, please describe
Did the patient have additional diseases/conditions?
Additional other diseases / conditions
Status or development of the disease/condition
Was any treatment given for the disease/condition?
If treatment was provided, please describe
Status or development of the disease/condition
Was any treatment given for the disease/condition?
If treatment was provided, please describe