Adverse even contact 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.

* Required fields

Contact person

Medical speciality *

specify

Date of birth

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

Name of the drug *

Reason for use of the prescription drug

Batch number

Description of adverse reaction(s)

Date of occurrence

specify

Any information provided will be confidential, respecting the privacy of personal data and medical and professional secrecy.

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