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About
Facility
R&D
Marketing
Products
Contact
Menu
About
Facility
R&D
Marketing
Products
Contact
ADVERSE EVENT REPORTING
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NAME OF PHARMIS LIMITED PRODUCT
*
The Product that you found any anamoly or adverse effect.
NATURE OF EVENT
*
ADVERSE/SIDE EFFECT
PRODUCT COMPLAINT (E.G. DEFECTS/MALFUNCTIONS)
PATIENT NAME
*
GENDER
*
MALE
FEMALE
DATE OF BIRTH
*
PREGNANT
*
SELECT ONE OPTION
YES
NO
EVENT DESCRIPTION
*
DESCRIPTION OF ADVERSE EVENT / SIDE EFFECT / ANY OTHER EXPERIENCE SUCH AS LACK OF EFFECT, MEDICATION ERROR
Suspect Drug details(Unit dose/strength & Form)
Dosage/ Unit/ Frequency
*
Route
*
TREATMENT START DATE
*
TREATMENT END DATE
*
LOT/BATCH
*
EXPIRATION DATE
*
RELEVANT MEDICAL HISTORY (IF AVAILABLE)
*
REPORTER FULL NAME
*
REPORTER NUMBER
*
REPORTER ADDRESS
*
REPORTER EMAIL
*
REPORTER PHONE NUMBER
*
ARE YOU ALSO THE PATIENT?
*
YES
NO
RELATIONSHIP WITH PATIENT
*
Submit