{"id":265,"date":"2022-12-02T11:56:48","date_gmt":"2022-12-02T11:56:48","guid":{"rendered":"https:\/\/alkalon.com\/?page_id=265"},"modified":"2023-03-15T10:49:05","modified_gmt":"2023-03-15T10:49:05","slug":"form","status":"publish","type":"page","link":"https:\/\/alkalon.com\/index.php\/form\/","title":{"rendered":"Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"265\" class=\"elementor elementor-265\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-14c01b4 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"14c01b4\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-efae2d5\" data-id=\"efae2d5\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-47d85d4 elementor-widget elementor-widget-text-editor\" data-id=\"47d85d4\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p style=\"text-align: center;\">Report a side effect<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-fedbbfe elementor-widget elementor-widget-text-editor\" data-id=\"fedbbfe\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p style=\"text-align: center;\">If you or the person you are reporting on behalf of are currently\u00a0suffering from severe side effects, you should contact your local doctor\u00a0or other medical health professional before reporting the side effect.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-97a565a elementor-widget elementor-widget-text-editor\" data-id=\"97a565a\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p style=\"text-align: center;\">All medicines have potential side\u00a0<span style=\"color: var( --e-global-color-text ); font-size: var( --e-global-typography-primary-font-size );\">effects as well as benefits.\u00a0<\/span><\/p>\n<p style=\"text-align: center;\"><span style=\"color: var( --e-global-color-text ); font-size: var( --e-global-typography-primary-font-size );\">We\u00a0<\/span><span style=\"color: var( --e-global-color-text ); font-size: var( --e-global-typography-primary-font-size );\">routinely monitor the safety and\u00a0quality of all our products.\u00a0<\/span><\/p>\n<p style=\"text-align: center;\"><span style=\"color: var( --e-global-color-text ); font-size: var( --e-global-typography-primary-font-size );\">This\u00a0<\/span><span style=\"color: var( --e-global-color-text ); font-size: var( --e-global-typography-primary-font-size );\">includes review of safety data from<\/span>\u00a0and review of side\u00a0effects and\u00a0<br>by\u00a0monitoring quality and safety information on our products, we can\u00a0<span style=\"color: var( --e-global-color-text ); font-size: var( --e-global-typography-primary-font-size );\">take due and appropriate actions to\u00a0<\/span><span style=\"color: var( --e-global-color-text ); font-size: var( --e-global-typography-primary-font-size );\">safeguard patient safety.<\/span><\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-b89ca81 elementor-widget elementor-widget-heading\" data-id=\"b89ca81\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h4 class=\"elementor-heading-title elementor-size-default\">About side effects reporting<\/h4>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-1ecccc8 elementor-widget elementor-widget-text-editor\" data-id=\"1ecccc8\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>Why you should report side effects<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-c3840fc elementor-widget elementor-widget-text-editor\" data-id=\"c3840fc\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p style=\"text-align: center;\">In case of a severe side effect taking place, seek\u00a0immediate help from your local hospital or healthcare\u00a0professional!<\/p>\n<p style=\"text-align: center;\">If you have experienced a side effect to a Alkalon A\/S product,<br>we\u00a0encourage you to also report this to Alkalon A\/S<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-8fc497e elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"8fc497e\" data-element_type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-acb468a\" data-id=\"acb468a\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-8d55bf6 elementor-widget elementor-widget-text-editor\" data-id=\"8d55bf6\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>Reporter information<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-cc8b407 elementor-widget elementor-widget-text-editor\" data-id=\"cc8b407\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p style=\"text-align: center;\">What information to provide.\u00a0When reporting side effects please provide the following information if possible:<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-e11f59c elementor-widget__width-inherit elementor-widget elementor-widget-wpforms\" data-id=\"e11f59c\" data-element_type=\"widget\" data-widget_type=\"wpforms.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"wpforms-container wpforms-container-full wpforms-form inputtypesubmithover inputtypesubmitactive buttontypesubmithover buttontypesubmitactive wpforms-page-buttonhover wpforms-page-buttonactive  background-color ddd  Darker grey background  border 1px solid ccc Lighter border \" id=\"wpforms-282\"><form id=\"wpforms-form-282\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"282\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php\/wp-json\/wp\/v2\/pages\/265\" data-token=\"d05e43d26b235db03a06fc6ed413eb05\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-field-container\"><div id=\"wpforms-282-field_20-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"20\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-282-field_20\">Layout<\/label><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-282-field_1-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-282-field_1\">Name <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-282-field_1\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][1]\" placeholder=\"Fill in name\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-282-field_3-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-282-field_3\">Location <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-282-field_3\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][3]\" placeholder=\"Fill in country\" required><\/div><\/div><\/div><\/div><div id=\"wpforms-282-field_5-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"5\"><label class=\"wpforms-field-label\" for=\"wpforms-282-field_5\">Patient details <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-282-field_5\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-282-field_5_1\" name=\"wpforms[fields][5]\" value=\"Female\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-282-field_5_1\">Female<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-282-field_5_2\" name=\"wpforms[fields][5]\" value=\"Male\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-282-field_5_2\">Male<\/label><\/li><\/ul><\/div><div id=\"wpforms-282-field_7-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"7\"><label class=\"wpforms-field-label\" for=\"wpforms-282-field_7\">Age <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-282-field_7\" class=\"wpforms-field-large wpforms-field-required wpforms-masked-input\" data-rule-inputmask-incomplete=\"1\" data-inputmask-mask=\"99\" name=\"wpforms[fields][7]\" placeholder=\"Patient&#039;s age\" required><\/div><div id=\"wpforms-282-field_8-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"8\"><label class=\"wpforms-field-label\" for=\"wpforms-282-field_8\">Reporter details <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-282-field_8\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][8]\" placeholder=\"Name\" required><\/div><div id=\"wpforms-282-field_10-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-282-field_10\">Contact details <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"email\" id=\"wpforms-282-field_10\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][10]\" placeholder=\"E-mail\" spellcheck=\"false\" required><\/div><div id=\"wpforms-282-field_22-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"22\"><label class=\"wpforms-field-label\" for=\"wpforms-282-field_22\">Phone no. <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-282-field_22\" class=\"wpforms-field-large wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][22]\" placeholder=\"Phone\" required><\/div><div id=\"wpforms-282-field_13-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"13\"><div id=\"wpforms-282-field_13\" class=\"wpforms-field-medium wpforms-field-row\" name=\"wpforms[fields][13]\"><h4>Product details<\/h4>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-282-field_9-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-282-field_9\">Name of the product <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-282-field_9\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][9]\" placeholder=\"Name\" required><\/div><div id=\"wpforms-282-field_23-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"23\"><label class=\"wpforms-field-label\" for=\"wpforms-282-field_23\">Batch no.  <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-282-field_23\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][23]\" placeholder=\"Number\" required><\/div><div id=\"wpforms-282-field_14-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-282-field_14\">What was the product taken for? <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-282-field_14\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][14]\" placeholder=\"Description\" required><\/div><div id=\"wpforms-282-field_16-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"16\"><label class=\"wpforms-field-label\" for=\"wpforms-282-field_16\">How do you take the product (dose, how often and how long?) <span class=\"wpforms-required-label\">*<\/span><\/label><textarea id=\"wpforms-282-field_16\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][16]\" placeholder=\"Description\" required><\/textarea><\/div><div id=\"wpforms-282-field_17-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"17\"><div id=\"wpforms-282-field_17\" class=\"wpforms-field-medium wpforms-field-row\" name=\"wpforms[fields][17]\"><h4>Side effect details<\/h4>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-282-field_18-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"18\"><label class=\"wpforms-field-label\" for=\"wpforms-282-field_18\">What happened? <span class=\"wpforms-required-label\">*<\/span><\/label><textarea id=\"wpforms-282-field_18\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][18]\" placeholder=\"Description\" required><\/textarea><\/div><div id=\"wpforms-282-field_25-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"25\"><label class=\"wpforms-field-label\" for=\"wpforms-282-field_25\">Please describe outcome: <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-282-field_25\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-282-field_25_1\" name=\"wpforms[fields][25]\" value=\"Recovered completely\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-282-field_25_1\">Recovered completely<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-282-field_25_2\" name=\"wpforms[fields][25]\" value=\"Recovering\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-282-field_25_2\">Recovering<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-282-field_25_3\" name=\"wpforms[fields][25]\" value=\"Recovered with lasting effects\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-282-field_25_3\">Recovered with lasting effects<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-282-field_25_4\" name=\"wpforms[fields][25]\" value=\"Not recovered\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-282-field_25_4\">Not recovered<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-282-field_25_5\" name=\"wpforms[fields][25]\" value=\"Not known\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-282-field_25_5\">Not known<\/label><\/li><\/ul><\/div><div id=\"wpforms-282-field_19-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"19\"><label class=\"wpforms-field-label\" for=\"wpforms-282-field_19\">Did you receive treatment for the side effect? <span class=\"wpforms-required-label\">*<\/span><\/label><textarea id=\"wpforms-282-field_19\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][19]\" placeholder=\"Description\" required><\/textarea><\/div><div id=\"wpforms-282-field_27-container\" class=\"wpforms-field wpforms-field-hidden\" data-field-id=\"27\"><input type=\"hidden\" id=\"wpforms-282-field_27\" name=\"wpforms[fields][27]\"><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"282\"><input type=\"hidden\" name=\"wpforms[author]\" value=\"1\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-282\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img decoding=\"async\" src=\"https:\/\/alkalon.com\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container -->\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-b6c80d9 elementor-widget elementor-widget-text-editor\" data-id=\"b6c80d9\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>Your privacy when reporting<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-c68818a elementor-widget elementor-widget-text-editor\" data-id=\"c68818a\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>We register reported product complaints and side effects\u00a0<\/p><p>For the sake of patients safety and also to comply with legislations.\u00a0<span style=\"color: var( --e-global-color-text ); font-size: var( --e-global-typography-primary-font-size );\">Your personal data will be entered and kept in the\u00a0Alkalon A\/S global safety database and will be treated\u00a0confidentially.<\/span><\/p><p>We report product complaints and side effects to\u00a0Health Authorities in accordance with legislation.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Report a side effect If you or the person you are reporting on behalf of are currently\u00a0suffering from severe side effects, you should contact your local doctor\u00a0or other medical health professional before reporting the side effect. All medicines have potential side\u00a0effects as well as benefits.\u00a0 We\u00a0routinely monitor the safety and\u00a0quality of all our products.\u00a0 This\u00a0includes &hellip; <\/p>\n<p class=\"link-more\"><a href=\"https:\/\/alkalon.com\/index.php\/form\/\" class=\"more-link\">Continue reading<span class=\"screen-reader-text\"> &#8220;Form&#8221;<\/span><\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_header_footer","meta":{"footnotes":""},"class_list":["post-265","page","type-page","status-publish","hentry","entry"],"_links":{"self":[{"href":"https:\/\/alkalon.com\/index.php\/wp-json\/wp\/v2\/pages\/265","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/alkalon.com\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/alkalon.com\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/alkalon.com\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/alkalon.com\/index.php\/wp-json\/wp\/v2\/comments?post=265"}],"version-history":[{"count":139,"href":"https:\/\/alkalon.com\/index.php\/wp-json\/wp\/v2\/pages\/265\/revisions"}],"predecessor-version":[{"id":555,"href":"https:\/\/alkalon.com\/index.php\/wp-json\/wp\/v2\/pages\/265\/revisions\/555"}],"wp:attachment":[{"href":"https:\/\/alkalon.com\/index.php\/wp-json\/wp\/v2\/media?parent=265"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}