www.digisupport.uk
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195.78.82.187
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URL:
https://www.digisupport.uk/
Submission: On July 16 via automatic, source certstream-suspicious — Scanned from FR
Submission: On July 16 via automatic, source certstream-suspicious — Scanned from FR
Form analysis 1 forms found in the DOM
Name: questionnaire — POST
<form name="questionnaire" method="post" id="form_questionnaire" autocomplete="nope" class="form-horizontal needs-validation panel panel-info">
<div class="step step-1">
<div class="questionnaire-title">
<h2 style="font-size: 1.5rem;">DigiSupport Patient Form</h2>
</div>
<p style="font-size: 1rem;">Register to our dedicated Patient Support Programme (PSP), where you will be able to :</p>
<br>
<ul>
<li style="font-size: 1rem;margin-left:20px;list-style-type:initial;">Onboard with one of our agents during a video call</li>
<li style="font-size: 1rem;margin-left:20px;list-style-type:initial;">Use Digihaler® to its full potential</li>
<li style="font-size: 1rem;margin-left:20px;list-style-type:initial;">Get help with downloading the Digihaler® app. Find out how to use the app with your Digihaler®. You will have access to a free helpline</li>
</ul>
<br><br>
<div>
<div class="input ">
<label>Status*</label>
<div>
<select id="questionnaire_civilite" name="questionnaire[civilite]" required="required" class="form-control form-control">
<option value="" selected="selected">---</option>
<option value="1">Ms</option>
<option value="2">Mrs</option>
<option value="3">Mr</option>
<option value="4">Doctor</option>
<option value="5">Other</option>
</select>
<div class="invalid-feedback"> Status required!</div>
</div>
</div>
</div>
<div class="double-input">
<div class="input">
<label>Surname*</label>
<div>
<input type="text" id="questionnaire_nom" name="questionnaire[nom]" required="required" data-error="Cette valeur ne doit pas être vide." class="form-control form-control">
<div class="invalid-feedback"> Surname required!</div>
</div>
</div>
<div class="input">
<label>First Name*</label>
<div>
<input type="text" id="questionnaire_prenom" name="questionnaire[prenom]" required="required" data-error="Cette valeur ne doit pas être vide." class="form-control form-control">
<div class="invalid-feedback"> First Name required!</div>
</div>
</div>
</div>
<div class="double-input">
<div class="input">
<label>Date of Birth*</label>
<div>
<input type="date" id="questionnaire_dateNaissance" name="questionnaire[dateNaissance]" required="required" class="form-control form-control">
<div class="invalid-feedback"> Date of Birth required!</div>
</div>
</div>
<div class="input">
<label>Name of the treatment *</label>
<div>
<select id="questionnaire_traitement" name="questionnaire[traitement]" required="required" class="form-control form-control">
<option value="" selected="selected">---</option>
<option value="17">GoResp Digihaler </option>
</select>
<div class="invalid-feedback"> Treatment required!</div>
</div>
</div>
</div>
<div class="double-input">
<div class="input">
<label>E-mail*</label>
<div>
<input type="email" id="questionnaire_email" name="questionnaire[email]" required="required" class="form-control form-control">
<div class="invalid-feedback"> E-mail required !</div>
</div>
</div>
<div class="input">
<label class="specialite">Phone*</label>
<div>
<input type="text" id="questionnaire_telephoneMobile" name="questionnaire[telephoneMobile]" required="required" class="form-control form-control" pattern="(\+44s?)?0?(\d{10,15})">
<div class="invalid-telephoneMobile none"> Phone required!</div>
</div>
</div>
</div>
<div>
<div class="form-check form-check-inline" style="display: -webkit-box;">
<div class="checkbox"> <label class="required"><input type="checkbox" id="questionnaire_papier" name="questionnaire[papier]" required="required" class="form-check-input" style="margin-top: 8px" value="1"> </label>
</div>
<label class="form-check-label" for="questionnaire_patient[cgv]"> I consent to the sharing of my contact details with Teva and its Patient Support Programme (PSP) provider, Webhelp, so that I can benefit from the Webhelp PSP services.</label>
<br><br> You can withdraw this consent at any time, but this will mean you are unable to participate in the Webhelp PSP. We will process your data for the purposes of providing the Webhelp PSP services. To find out more about how your data is
used in connection with Digihaler®, and your data protection rights, please see <a style="display: contents; color: cornflowerblue" href="/document/Digihaler Privacy Notice.pdf" target="_blank">Teva’s Digihaler® Privacy Notice</a>.
</div>
<div class="form-check form-check-inline">
<p style="border-width:1px; border-style:solid; border-color: black; padding: 1em; font-size: 12px; margin-top: 20px;">
<b>Intended for patients prescribed GoResp® Digihaler® (budesonide/ formoterol)</b><br> If you experience any side effects (adverse events), talk to your doctor, pharmacist or nurse. This includes any possible side effects not listed in the
Patient Information Leaflet. You can also report side effects directly via the Yellow Card Scheme at www.mhra.gov.uk/yellowcard. By reporting side effects you can help provide more information on the safety of this medicine. Side effects
may also be reported directly to Teva UK Limited at medinfo@tevauk.com or by calling 0207 540 7117.
</p>
</div>
</div>
<div class="questionnaire-title">
<p> </p>
</div>
<div class="alert alert-block alert-danger" style="display:none"> You must give an answer to this question </div>
<br>
<div align="center" class="form-group">
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<div class="g-recaptcha" data-sitekey="6LfknQInAAAAABROuHpkg_gjZTvmCoAgcaC4vkeV">
<div style="width: 304px; height: 78px;">
<div><iframe title="reCAPTCHA" width="304" height="78" role="presentation" name="a-7gngec5bhopd" frameborder="0" scrolling="no"
sandbox="allow-forms allow-popups allow-same-origin allow-scripts allow-top-navigation allow-modals allow-popups-to-escape-sandbox allow-storage-access-by-user-activation"
src="https://www.google.com/recaptcha/api2/anchor?ar=1&k=6LfknQInAAAAABROuHpkg_gjZTvmCoAgcaC4vkeV&co=aHR0cHM6Ly93d3cuZGlnaXN1cHBvcnQudWs6NDQz&hl=en&v=rKbTvxTxwcw5VqzrtN-ICwWt&size=normal&cb=42k77orsndu4"></iframe>
</div><textarea id="g-recaptcha-response" name="g-recaptcha-response" class="g-recaptcha-response"
style="width: 250px; height: 40px; border: 1px solid rgb(193, 193, 193); margin: 10px 25px; padding: 0px; resize: none; display: none;"></textarea>
</div><iframe style="display: none;"></iframe>
</div>
<div class="alert alert-block alert-danger" id="alert_captcha" style="display:none"> You must prove that you are not a robot </div>
</div>
</div>
<div class="buttons">
<div><button type="button" class="btn textbtn1 btn-secondary">Confirm</button></div>
<div><br><br>
<p>DGH-GB-NP-00062<br> Date of Preparation: July 2023</p>
</div>
<div class="desktopteva" style="position: absolute;right: 120px;bottom: 50px;text-align: center">
<p>Supported by</p>
<img src="/images/extranet/teva.png" style="height: 50px;margin-right:20px" alt="Promed">
</div>
</div>
<input type="hidden" id="questionnaire__token" name="questionnaire[_token]" value="VG6QlTbd1iY7IUfekdnbEc7WA8WC8cB94E6xdpQqJqc">
</form>Text Content
× YOUR REGISTRATION TO THE DIGISUPPORT PROGRAMME HAS BEEN VALIDATED. Our agents will contact you to book your onboarding call × You already subscribe to the programme! We sent you a mail to provide you with all the information you need. × INSCRIPTION PATIENT Le patient existe déjà dans la base de données du programme. Si il y a un problème, veuillez consulter le numéro vert du programme. × CONFIRMATION DE LA DEMANDE DE CRÉATION DE VOTRE COMPTE EXTRANET Votre inscription à l’extranet sera validée dans les 24h ouvrées. × LA COMMANDE A ÉTÉ EFFECTUÉ. Vous pouvez vérifier le statut de la commande en bas de la page de commande de documents. × For all questions, contact us on our free helpline number : 0800 102 6820 DIGISUPPORT PATIENT FORM Register to our dedicated Patient Support Programme (PSP), where you will be able to : * Onboard with one of our agents during a video call * Use Digihaler® to its full potential * Get help with downloading the Digihaler® app. Find out how to use the app with your Digihaler®. You will have access to a free helpline Status* ---MsMrsMrDoctorOther Status required! Surname* Surname required! First Name* First Name required! Date of Birth* Date of Birth required! Name of the treatment * ---GoResp Digihaler Treatment required! E-mail* E-mail required ! Phone* Phone required! I consent to the sharing of my contact details with Teva and its Patient Support Programme (PSP) provider, Webhelp, so that I can benefit from the Webhelp PSP services. You can withdraw this consent at any time, but this will mean you are unable to participate in the Webhelp PSP. We will process your data for the purposes of providing the Webhelp PSP services. To find out more about how your data is used in connection with Digihaler®, and your data protection rights, please see Teva’s Digihaler® Privacy Notice. Intended for patients prescribed GoResp® Digihaler® (budesonide/ formoterol) If you experience any side effects (adverse events), talk to your doctor, pharmacist or nurse. This includes any possible side effects not listed in the Patient Information Leaflet. You can also report side effects directly via the Yellow Card Scheme at www.mhra.gov.uk/yellowcard. By reporting side effects you can help provide more information on the safety of this medicine. Side effects may also be reported directly to Teva UK Limited at medinfo@tevauk.com or by calling 0207 540 7117. You must give an answer to this question You must prove that you are not a robot Confirm DGH-GB-NP-00062 Date of Preparation: July 2023 Supported by