REQUEST INFORMATION
Is Drug Effective YesNo
Is this report to inform about similarity between medication names, products, inappropriate, or missing and misleading information in packaging and labeling AND did not result in a medication error YesNo
The incident related to product Namepackaging /labelingBoth
How did you obtain the medication From the pharmacy with a prescriptionFrom the pharmacy without a prescriptionFrom other stores (not a pharmacy)
Gender MaleFemale
SUSPECTED DRUGS INFO (OPTIONAL)