Pv Form - Bausch + Lomb

Type of Inquiry*

Adverse Event/Side effectProduct Complaint

Reporter contact information/Initials*

Reporter Phone

Reporter e-mail address*

Province*

Reporter’s Profession*

Country of purchase*

USAMexicoCanadaOther

Other Country

Consent to Follow-up*

YesNo

Product/Drug name*

Dosage/Route/Frequency

Therapy Start date

Product Expiry date

Reason for use of B+L product*

Patient Initials*

Date of birth

Height/Weight of Patient

Patient age group*

Please select from below option

Gender*

FemaleMaleNon-binaryPrefer not to say

Ethnic Origin

Pregnancy at time of reaction/event/side effect

YesNoN/A

Has the patient contacted their HCP about the Adverse Event

YesNo

Does the patient give consent to contact their HCP if required.

YesNo

Did the reaction/Product issue/Adverse event Occur in Canada

YesNo

Please describe the Adverse reaction/Side effect/Product complaint*

Please describe Concomitant Medication (Include medications taken within 30 days before Adverse Reaction onset. Do not include medications taken as a treatment for the Adverse Reaction)

Please provide Relevant Tests/Laboratory Data (including dates) (yyyy-mm-dd)

Please provide Other Relevant History, Including Pre-existing Medical Conditions (e.g., allergies, pregnancy, smoking etc.)

Date signed *

Please note that we may need to process your personal data in order for us to address your inquiry. By submitting your information, you confirm you have read and agree with the terms of our Legal Notice & Privacy Policy - Bausch + Lomb

ADVERSE EVENT AND PRODUCT COMPLAINT REPORTING CANADA

Adverse Event/Product Complaint Form

Legal Notice & Privacy Policy