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 Email Address

Product Name *

Side Effect *

Patient Name and Surname Initials *

Patient Age

Patient Gender *

Patient Height (cm)

Patient Weight (kg)

Your message

I consent to the processing of my sensitive personal data that I have shared in the Side Effect Notification Form within the scope of the Privacy Policy and the Clarification Text on the Processing of Personal Data.

I hereby declare and undertake that I have provided the patient with the necessary information regarding the personal data of the patient that I have shared in this Side Effect Notification Form that I have filled out on behalf of the patient and that I have obtained his/her consent to share his/her personal data with you.

I consent to the transfer of the personal data I have shared in the Side Effect Notification Form abroad within the scope of the Privacy Policy and the Clarification Text on the Processing of Personal Data.