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Country of occurrence

PATIENT OR HEALTH CARE PROFESSIONAL?

Who notifies?

PRODUCT

Unauthorized product

Vaccination Date

BATCH Nº

Administration Route

DOSE ADMINISTERED

EXPIRATION DATE

Description of the case (describe the sequence of the events in detail)

SYMPTOMS OBSERVED

INITIAL DATE OF THE SYMPTOMS OBSERVED

If you do not know this information, leave blank.

END DATE OF THE SYMPTOMS OBSERVED OR ONGOING

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Initial date of the clinical signs

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End date of the clinical signs or ongoing

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Who reports the case

Animal data

Number of animal treated

Number of animal reacted

Number of dead animals

SERIOUSNESS

OUTCOME

Any relevant additional information

NAME (Reporter)

CITY/TOWN (Reporter)

Email (Reporter)

Gender (Patient)

NAME (patient)

HEIGHT (patient)

WEIGHT (patient)

AGE (patient)

ADDRESS (patient)

CITY/TOWN (Patient)

ZIP/POSTAL CODE (Patient)

COUNTRY (patient)

PHONE (patient)

Email (Patient)

PROFESSION (health care professional)

NAME (health care professional)

SURNAME (health care professional)

ADDRESS (Health Care Professional)

CITY/TOWN (Health Care Professional)

TELEPHONE (Health care professional)

COUNTRY (Health care professional)

Email (Health Care Professional)

Gender (Patient)

Initials (Patient)

Height (Patient)

Weight (Patient)

Age (Patient)

Email (Patient)

NAME (Health Care Professional)

CITY/TOWN (Health Care Professional)

Email (Health Care Professional)

Name

Surname

Country

Email address

Organisation

Position/Type of professional

Attachment

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2 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.

Your message

Basic Personal Data Protection information:

Controller: HIPRA, S.A.
Purposes: Managing the contractual and/or business relationship with HIPRA, including sending news, promotions and invitations to events sponsored by HIPRA.
Lawful basis: Performance of the contractual relationship and HIPRA’s legitimate interest.
Recipients: Third parties to which HIPRA has entrusted cloud computing, security, auditing, mailing, technical and computer support services, as well as companies in its group.
Rights: Request access to and rectification or erasure of personal data and other rights as explained in the additional information.
You can see the detailed additional information about data protection in our Privacy Policy.

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HIPRA'S PRIVACY POLICY

Contact details

HIPRA Headquarters

Avenida la Selva 135

17170 Amer (Girona)

Spain

Contact

Tel.: (+34) 972 43 06 60

Fax: (+34) 972 43 06 61

hipra@hipra.com

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asia_oceania@hipra.com

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europe@hipra.com

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