Report A Suspected Adverse Event

Submit a report for any suspected adverse event linked to a Virbac product

1 Contact details

2 Patient detail

3 Product information

Your name*

Email address*

Phone number*

Practice name*

Practice street name

Practice town/city

Practice postcode*

Product name

Strength

Pharmaceutical form

Date of administration*

Reason for use

I have used this product before*

Yes No

Has the patient received this product before? If so when?

Were any adverse reactions seen previously? If so please describe the nature, any treatment received, and the outcome

Describe clinical signs, date of onset and duration of suspected adverse reaction*

Has the animal recovered?

Has any treatment been given to treat the reaction?*

Yes No

Give more details here

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