HIPRA | Contact Us

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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

If you do not know this information, leave blank.

Initial date of the clinical signs

If you do not know this information, leave blank.

End date of the clinical signs or ongoing

If you do not know this information, leave blank.

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

Name

We recommend that you fill out this field.

Surname

We recommend that you fill out this field.

Country

Email address

Mobile Phone

Identity card number (DNI, NIE...)

Name (people involved)

Surname (people involved)

Department or area (people involved)

Description of the facts

Approximate date of events

Do the facts affect or can they affect third parties?

Please, indicate to whom

To any movable and/or immovable property?

Have these facts been reported previously?

Please, indicate an approximate date:

Please, indicate to whom

I declare I have not strayed from the truth, that the data and facts are true and complete, and that this communication is made in good faith.

This form allows anyone to report a behaviour or fact to the HIPRA Compliance department.

Organisation

Position/Type of professional

Attachment

One file only.
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.

I agree to receive informative or promotional notifications sent by HIPRA

I have read and agree to

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

Human Health Contact Centre

You can request more information at the corresponding country e-mail address or telephone number.

Afghanistan

asia_oceania@hipra.com

Albania

europe@hipra.com

Algeria

Around the world

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