Pharmacovigilance

Reporter Information

First Name* (required)

Last Name* (required)

Phone* (required)

E-mail* (required)

Gender(required)*

—Please choose an option—MaleFemale

Age(required)*

Patient/Consumer Information who experienced the adverse event

To avoid duplication of notifications, at least the initials of the first and last name are required

First Name* (required)

Last Name* (required)

Phone* (required)

E-mail* (required)

Gender*(required)

—Please choose an option—MaleFamele

Weight*

Height

Pregnancy*(required)

—Please choose an option—YesNo

Hospitalized*(required)

—Please choose an option—YesNo

Symptoms observed after using the medicine*(required)

Purpose of medicine use*(required)

Product or Medicine

Brand Name*(required)

Generic Name*(required)

Indication / Daily dosage*(required)

Start Date of Use*(required)

End Date

No. of doses received