HCP Form

Patient and Reporter Information

Please provide a response to at least 1 of the fields in Blue

Patient Initials

Date of Birth

Age (Years)

Gender

What is patient's gender

Other/ Prefer not to disclose

Your Contact Information

What is your qualification?

Your name/initials

Your Street Address

Your City

Your State/Province/County

Your Postal Code

Your Country Required

Does Teva have permission to contact you about this report?

Yes

Phone

E-mail

Does Teva have permission to contact the patient about this report?

Yes

Phone

E-mail

Product

What is the product you want to report about? Please include details such as dose, dosage form, frequency, route of administration

Please provide details about the product

Product Start Date

Product Stop Date

Indication

Batch/Lot number

Was the patient taking concomitant medication?

Yes

What is the product you want to report about? Please include details such as dose, dosage form, frequency, route of administration

Product Start Date

Product Stop Date

Indication

Batch/Lot number

Adverse Event

Please describe patient's adverse events or side effects here

When did patient's adverse event start?

When did patient's adverse event end?

Did the patient recover from the adverse event?

Narrative

Please include additional relevant information regarding the report

Medical History

Does the patient have other diagnosed illnesses / medical history / chronic health conditions? Please add details and dates. Please indicate if patient is a tobacco smoker or alcohol consumer.

Attach a file here

Consent to the processing of your personal data is required Required

I confirm that the details I have provided are correct

By clicking the "Submit" button, you confirm your consent to the processing of the personal data as provided in the report. Personal data will be used by Teva Pharmaceutical Industries Ltd. and its affiliates solely to meet our obligations, and may be transferred out of your country.

For more information on how Teva processes your personal data, including information on your data protection rights, please visit our privacy policy.

If you would like to review in your country language, please see the list below

Toggle Expand/ Collapse

International Markets
Australia
Argentina
Azerbaijan
Belarus
Brazil
China
Chile
Hong Kong
Israel
Indonesia
Japan
Kazakhstan
Kyrgyzstan
Mexico
Malaysia
New Zealand
Peru
Russia
Singapore
S. Africa
S. Korea
Turkey
Thailand
Ukraine
Uzbekistan
Venezuela
Vietnam

North America
Canada
United States

North America

International Markets

Europe