Drug Safety
Pharmacovigilance

Report an Adverse Event

1. Patient
2. Event
3. Reporter

Patient Initials*

Age / Date of Birth*

Gender*

Product Name*

Batch / Lot Number

Event Start Date*

Description of Symptoms*

Reporter Name*

Phone Number*

Email Address*

Confidentiality Assured
Handled per strict DRAP & WHO safety protocols.

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