Adverse Event

Report an Adverse Event

Reporter Details

Patient Details

Suspect Medicine Details

Adverse Reaction Details

Review and Submit

Reporter Details

Please fill-out the fields below with your contact information. This will help us contact you if ever we would need further information to address your report.

First Name

Middle Name

Last Name

Mobile Number

Email Address

Patient Details

Please provide us details of the individual who experienced the adverse reaction.

Age

Gender

Suspect Medicine Details

Please provide us the following details about the medicine consumed.

Brand Name

Generic Name

Dosage Strength

Lot / Batch Number

Manufacturing Date

Expiry Date

Establishment Where Medicine was Purchased

Date When Medicine was Purchased

Description of Adverse Reaction

Please tell us what happened: (Include as many details as possible)

Review and Submit

Please review the details before submitting

Reporter Details

First Name

Middle Name

Last Name

Mobile Number

Email Address

Patient Details

Age

Gender

Suspect Medicine Details

Brand Name

Generic Name

Dosage Strength

Lot / Batch Number

Manufacturing Date

Expiry Date

Establishment Where Medicine was Purchased

Date When Medicine was Purchased

Description of Adverse Reaction