VIGILANCE

VIGILANCE FORM

You are about to report an adverse reaction/situation involving a drug. Your report will be handled by a TEDIS pharmacovigilance officer, who may need to contact you shortly.

Head office

9, avenue d’Ouessant 91140 Villebon-sur-Yvette (France)
+33 (1) 64 53 15 64
contact@tedis.fr

Cold Chain office

3, rue de la croix brisée 91320 Wissous
contact@tedis.fr

Contact

Contact pharma EN

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Personal informations

Subsidiary*

I am*

Date of birth*

First Name*

Name*

Address

Town

Zip code

Country*

E-mail address*

Phone number

Information on the exposed person

Sex*

Date of birth

First Name (1rst letter)

Name (3rst letters)

Medicine concerned

Name of the medication*

Reason for drug use

Batch number

Description of indésirable effects*

Date of occurence

Sate of recovery

All information provided will be treated with respect for the confidentiality of personal data, medical and professional secrecy.