AE/SideeffectOverdosePregnancy or lactationMisuseDrug AbuseProduct Complaint
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Patient Initials*
Gender MaleFemaleOthers
Age*
Date of Birth*
Reason(s) for Taking Medicine(s)*
Medicines Advised by* Select AdvisorAdvisor 1Advisor 2Advisor 3
Name of Reporter*
Email ID*
Contact Number*
Address Line 1*
Address Line 2
City*
State*
Country*
Medicine Name*
Dosage form*
Dose of Medicine*
Batch No.*
Expiry Date*
Start Date*
Stop Date*
—Please choose an option—TabletCapsulesPelletsSachets -+
Description
What did the adverse effect start:*
What did the adverse effect stop:*
Adverse effect is still continuing: YesNo
Did not affect dailyAffect daily activitiesAdmitted to hospitalDeathOther
*This reporting is voluntary, has no legal implication and aims to improve patient’s safety. Your active participation is valuable. This information provided in this form will be forwarded to our PV department for follow up. You are requested to cooperate with the PV officials when they contact you for more details. Please do report even if you don’t have all the information.
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