Compassionate Use Request Details

***to be completed by the licensed prescriber electronically***
(Note “NA” for items not applicable.)

Contact Information

1. Name of requester: (required)

2. Name of institution/ regulatory agency (if applicable):

3. Requester address:

4. Requester phone number:

5. Requester email: (required)

6. Additional Contact email and phone number, if applicable:

Proposal Information

7. Name of medicine being requested:

8. Type of Compassionate Use Request:

Patient

Group

9. If this is a Group request, please provide any applicable details of program or attach a protocol, if available (do not include any patient identifiable information or personal data):

NOTE: If no protocol is attached, please complete items 9-13 below. If a protocol is attached, you may indicate “see attached” in items 9-13 as long as the information is included in the protocol.

10. Description of patient/patient group disease or condition including a comprehensive summary of the medical history. Do not include any patient identifiable information or personal data; instead, provide either patient ID and study number (if the patient previously participated in Teva study) or initials:

11. Rationale for compassionate use of the medicine:

12. Proposed patient/patient group treatment plan, including dose and duration:

13. Do you consider the treatment to provide a positive risk/benefit, and why?:

14. Proposed Procedures for Safety Monitoring:

Treating Physician and Site Experience and Capabilities

15. Is the treating physician licensed and qualified to administer medicine for compassionate use (provide pertinent information [e.g., or attach CV, medical license to email]):

16. Attach a file

Please upload a file up to 10MB

17. Medicine storage capability:

Medicine Cost and Teva Expenses

18. Is free medicine requested?

Consent to the processing of your personal data

I confirm that the details I have provided are correct

Data Protection Information:
The information you provide in this form will be processed and stored by the Global Medical Affairs Department of Teva Pharmaceutical Industries Ltd. and affiliates (as necessary) (“Teva”) solely for the purposes of processing your request and in accordance with applicable data privacy laws. For more information on how Teva processes your personal data, please visit our Global Privacy Notice.

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Compassionate Use Request Details

Contact Information

Proposal Information

Treating Physician and Site Experience and Capabilities

Medicine Cost and Teva Expenses

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