Pharmaceutical Incident - Boehringer Ingelheim Animal Health

Fields identified with a * must be completed (enter "Unknown" or "N/A" if appropriate).

Please complete as many entries as possible.

Veterinarian(s)*

Other Contact (if applicable) Also indicate role, such as AHT, RVT, Hospital Manager, etc.

Veterinary Practice Name*

Telephone Number*

Fax Number

E-mail Address* A copy of the report will be sent automatically to this address upon submission

Boehringer Ingelheim
Territory Manager Name

Animal Owner Name(s)*

Telephone Number*

Fields identified with a * must be completed (enter "Unknown" or "N/A" if appropriate).

Please complete as many entries as possible.

IMPORTANT: Please indicate ALL products administered before the incident occurred.

BOEHRINGER INGELHEIM PHARMACEUTICAL(S)

Boehringer Ingelheim Pharmaceutical*

Other Product*

Original Container Size, Lot/Serial Number and Expiry*

Dose & Frequency, Administration Route and Site*

Dates of First and
Last Administration*

Reason for Use*

Administered By*

Veterinarian

RAHT/RVT/AHT/VT

Other clinic staff

Animal owner

Other (please specify in incident information section)

This Patient*

Never received this product before

Received this product before without any reaction

Received this product before and reacted
(please provide details in next section)

Unknown

Please provide details on previous use or reactions to this product:

IMPORTANT: Please indicate ALL products administered before the incident occurred.

Please complete as many entries as possible.

All other product(s) administered before the incident (drugs, parasiticides, supplements, vaccines, etc.)
Note: Please list all products used for general anesthesia individually

Product (Manufacturer, Product)

Lot/Serial Number and Expiry

Dosage, Administration Dates (first and last), Route, Reason For Use

This patient never received this product before

This patient received this product before without any reaction

This patient received this product before and reacted(please provide details in next section)

Unknown

Administered By*

Veterinarian

RAHT/RVT/AHT/VT

Other clinic staff

Animal owner

Other (please specify in incident information section)

Please provide details on previous use(s) and/or reaction(s) for this product:

Please provide details on suspected reactions to any other drugs, vaccines, or other products in this pet, including food allergies/intolerances:

Fields identified with a * must be completed (enter "Unknown" or "N/A" if appropriate).

Please complete as many entries as possible.

Possible Lack of
Efficacy?

If you report a possible lack of efficacy, please check

Date of Onset* DD-MMM-YYYY - Please give the date of the onset of the incident;
indicate if date is unknown or approximate

Delay of Onset* Please give the delay between administration of product(s) and onset of
event; indicate if unknown or approximate

Please provide a full
description of the reaction including dates, clinical signs, diagnostic
procedures with results if available, and outcome*

Please describe the
treatments (dates and
details of medication, fluid therapy, nutrition, etc.)*

Using the buttons below, please attach the medical records and all appropriate supporting documents, such as anesthesia records,
laboratory results, medical imagery or photographs, from your computer. Use a different button for each upload.

PLEASE NOTE THAT THE PATIENT’S MEDICAL RECORDS ARE REQUIRED FOR
PROPER ANALYSIS OF THIS PHARMACEUTICAL INCIDENT.

You can also send the documents by email to vetpv@boehringer-ingelheim.com or by fax at 1-888-550-5395.

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Use the button below to submit your report and the supporting documentation.

Once you have submitted your report successfully, you will be taken to a new webpage.

You will also receive a copy of your report at the email address you provided.

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Thank you for sending your report!

A copy of the report has also been sent to your email address.

Confirmation #:

All reports received are investigated, assessed and reported to the authorities, based on the information you have provided. You may be contacted for additional information.
A permanent case number will also be sent to you by email once entered in our database.

For any question, please call us at 1-877-565-5501.
You can also contact us by email: vetpv@boehringer-ingelheim.com

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Fields identified with a * must be completed (enter "Unknown" or "N/A" if appropriate).

Please complete as many entries as possible.

Fields identified with a * must be completed (enter "Unknown" or "N/A" if appropriate).

Please complete as many entries as possible.

Fields identified with a * must be completed (enter "Unknown" or "N/A" if appropriate).

Please complete as many entries as possible.

IMPORTANT: Please indicate ALL products administered before the incident occurred.

BOEHRINGER INGELHEIM PHARMACEUTICAL(S)

IMPORTANT: Please indicate ALL products administered before the incident occurred.

Please complete as many entries as possible.

All other product(s) administered before the incident (drugs, parasiticides, supplements, vaccines, etc.) Note: Please list all products used for general anesthesia individually

Fields identified with a * must be completed (enter "Unknown" or "N/A" if appropriate).

Please complete as many entries as possible.

PLEASE NOTE THAT THE PATIENT’S MEDICAL RECORDS ARE REQUIRED FORPROPER ANALYSIS OF THIS PHARMACEUTICAL INCIDENT.

Use the button below to submit your report and the supporting documentation.

Thank you for sending your report!

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All other product(s) administered before the incident (drugs, parasiticides, supplements, vaccines, etc.)
Note: Please list all products used for general anesthesia individually

PLEASE NOTE THAT THE PATIENT’S MEDICAL RECORDS ARE REQUIRED FOR
PROPER ANALYSIS OF THIS PHARMACEUTICAL INCIDENT.