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Patient Information

Patient initial:*

Age group:*

Age group:*
MaleFemale

Are you pregnant?*
YesNo

Weight: (KG)

Hight: (CM)

Adverse Event Information:

Describe Adverse Event:*

Product Information

Product name:*

Indication:

Batch No.:

Institution name and address:

Route of Administration:*

Reporter Information:

Reporter Name:*

Address:

Mobile:*

E-Mail:

Relative Relation:

* Required Fields

Pharmacovigilance Privacy Note :
By sending us your adverse event report, you may provide us with personal information. Our policy is to ask only for the minimum amount of personal information necessary to answer your query. Prior to handling your query or adverse event report we are required to obtain your consent. By submitting this form, you confirm that it is acceptable for us to use your personal information for the purposes of resolving your query or addressing your adverse event report.