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Patient Information
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Age group:
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Neonate (birth – 1 month)
Infant (1 month – 2 years)
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Are you pregnant?
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Weight: (KG)
Hight: (CM)
Adverse Event Information:
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Product Information
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Indication:
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Institution name and address:
Route of Administration:
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Oral
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Subcutaneous
Reporter Information
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Address:
Mobile:
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+9665
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