Vaccine 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 at the time of vaccination.

VACCINE(S)

Vaccine Name*

Other Vaccine
(Manufacturer, Product)*

Lot/Serial Number and Expiry*

Administration Date* DD-MMM-YYYY; please indicate if unknown or approximate

Administration Route & Site*

Administered By*

Veterinarian

RAHT/RVT/AHT/VT

Other clinic staff

Animal owner

Other (please specify in incident information section)

This Patient*

Never received this vaccine before

Received this vaccine before without any reaction

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

Unknown

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

IMPORTANT: Please indicate ALL products administered at the time of vaccination.

Please complete as many entries as possible.

Other product(s) administered at the time of vaccination
(drugs, parasiticides, supplements, 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 vaccines, drugs or other products, including food allergies/intolerances:

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 VACCINAL 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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Second document to attach

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Third document to attach

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Fourth document to attach

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Fifth document to attach

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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.

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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 at the time of vaccination.

VACCINE(S)

IMPORTANT: Please indicate ALL products administered at the time of vaccination.

Please complete as many entries as possible.

Other product(s) administered at the time of vaccination (drugs, parasiticides, supplements, 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 VACCINAL INCIDENT.

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

Thank you for sending your report!

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Other product(s) administered at the time of vaccination
(drugs, parasiticides, supplements, 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 VACCINAL INCIDENT.