REPORTING FORM

1 Patient Info

2 Medicine

3 Facility

4 Reporter & Upload

Note:

Submission of a report does not constitute an admission that medical personnel or manufacturer or the product caused or contributed to the reaction.
Submission of report does not have any legal implication on the reporter.

A. Patient Information

1. Name *		3. Gender *
2. Age / DOB *		4. Weight (Kgs)
5. Address
6. Event Reaction Start Date		7. Event Reaction Stop Date
8. Allergies
9. Previous Adverse Event
10. Chronic Conditions

B. Medicine Information

Medicine	Manufacturer	Batch No	Expiry	Route	Frequency

12. Therapy Start Date		13. Therapy Stop Date
14. Indication
15. Causality Assessment

C. Facility / Hospital

13. Facility Name *
14. Facility Address
15. Doctor Name

D. Reporter Information

16. Reporter Name *		17. Relation
18. Occupation		22. Mobile *
21. Email *
20. Address
19. Additional Info

Upload Documents

23. Upload PDF (Max 10MB)

Upload PDF (Max 10MB)

Sample PDFs for testing: sample-report-1.pdf, sample-report-2.pdf, sample-report-3.pdf