Drug Safety

Patient Information

Initials*

Gender *

Age *

Country *

Suspected Drug Details

Drug Name/s*

(If it is more than one drug please use comma)

Name of Disease for Which Drug was Used

(Indication)

Batch / Lot Number

Dose and Frequency

Manufacturer/Marketer

Dosage

Start Date

Stop Date

Pregnancy Exposure

Last Date of Menstrual Cycle

Expected Delivery Date

Reporter Information

Telephone Number*

Email Address*

Name*

Profession / Qualification*

Additional Information

(provide information about your medical history, other medications or any laboratory finding/s you would think would help)

Permission to Contact HCP

If “Yes”, please provide your doctor’s contact details

Name of Doctor

Contact Number

Email Address*

Mailing Address

Please type the characters*

This helps us prevent spam, thank you.

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