Looking for Something?

AR

Looking for something?

Pharmacovigilance Form

What is the name of the product you want to report? *

When did the person experiencing the side effects start taking the medicine?

Start date:

End date:

What is the side effect that you want to report? *

What is the gender of the person experiencing the side effect? *

Male
Female

Contact Details

Email Address

Phone Number *

Is reporter the patient?

Yes
No

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