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Caregiver Form

Patient and Reporter information

Patient's Initials:

What is your Date of Birth?

What is your age (years)?

Gender

Your Contact Information

Your name/initials

Your Street Address

Your City

Your State/Province/County

Your Postal Code

Your Country Required

Your Phone

Your E-mail (Preferred)

Does Teva have permission to contact you about this report?

Yes

Your phone

Your E-mail

Does Teva have permission to contact the patient's healthcare provider about this report?

Yes

Health Care Provider (HCP) Contact Information

First Name

Last Name

Qualification

Your Country Required

Phone

E-mail

Product

What is the product (Brand name) 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

You can find this information on the product package. This is mandatory field for biologic products. If the Batch is unknown, please write "unknown".

Expiration Date

Health Authority product identifier number

e.g. NDC number, approval number etc. The number can be found on the product package.

Was the patient taking other medication at the time of the event?

Yes

What is the product (Brand name) 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

You can find this information on the product package. This is mandatory field for biologic products. If the Batch is unknown, please write "unknown".

Expiration Date

Health Authority product identifier number

e.g. NDC number, approval number etc. The number can be found on the product package.

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? required

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 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 https://www.tevapharm.com/our-company/corporate-governance/teva-privacy-notice/

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

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Caregiver Form

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

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