Vigilance form

You are notifying an adverse event/situation involving a medical drug. A person in charge of pharmacovigilance at Pierre Fabre will handle your notification and she/he may contact you.

If you have any questions about your state of health, please consult your physician.

* Required fields

Contact person

Medical speciality *

specify

First name *

Last name *

Address

City

Postal Code

Country *

Email *

Phone number

Fax number

Information on the exposed patient

Date of birth

First name (First letter)

Last name (First 3 letters)

Prescription drug concerned

Type of Pierre Fabre Product Involved *

Name of the drug *

Reason for use of the prescription drug

Batch number

Start date of treatment

Expiration date

Description of adverse reaction(s)

Date of occurrence

specify

By completing this form, I certify that the information provided is accurate. *

All information and personal data you share with us through this form will be protected and kept confidential in accordance with our company policy and applicable regulations.

The data collected about you will be processed electronically by Pierre Fabre SA, in compliance with the General Data Protection Regulation (GDPR) of 27 April 2016, for the purpose of monitoring the tolerability of our products and may be shared with health authorities, as the processing of your personal data is necessary to comply with a legal obligation to which Pierre Fabre is subject.

Please note that this data will be stored for a maximum period of 50 years.

As the processing of your data is necessary to comply with a legal obligation, you have the right to access, rectify, and restrict the processing of your personal data. You can exercise these rights by contacting us at dpofr@pierre-fabre.com.

You have the right to lodge a complaint with your national supervisory author.

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