Advers Event Form

In case of occurrence of any adverse event related products Proceutica, Turkey Pharmacovigilance Center - referring to TÜFAM (www.titck.gov.tr; tufam@titck.gov.tr; Tel: 0 800 314 00 08, Fax: 0 312 218 35 99) or 0 850 480 77 76 or by filling out the form below. The form you filled out will be forwarded to proceutica@deltapv.com. By reporting the adverse events that occur, you will contribute to obtaining more information about the safety of the drug you are using.

First and Last Name Initials *

Your Phone Number *

Your E-Mail Address

Product Name *

Side Effect *

Patient Name and Surname Initials *

Patient Age

Patient Gender *

Patient Height (cm)

Patient Weight (kg)

Your Message

I have read and understood the Clarification Text on the Processing of Personal Data within the Scope of Side Effect Notifications regarding the conditions under which my personal data shared in the Side Effect Notification Form will be processed. I accept the accuracy of the information I have provided in this context.

I declare and undertake that I have provided the necessary information to the patient regarding the personal data I have shared in this Side Effect Notification Form that I have filled out on behalf of the patient. In this context, I accept the accuracy of the information I have provided.

Please mark it as 'I'm not a robot'
* Marked fields are mandatory fields, please do not leave blank.

Advers Event Form

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