Report an Adverse Event

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    CONTACT INFORMATION


    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)



    PATIENT INFORMATION (OPTIONAL)




    PRODUCT DETAILS (OPTIONAL)





    Did you stop using the medication? YesNo

    SIDE EFFECT (OPTIONAL)


    Did you inform the doctor or pharmacist of these adverse event? YesNoUnknownIf Yes, Did he/she file an adverse event reporting form? YesNoUnknownCan we obtain further information from your treating physician YesNo

    CONCOMITANT DRUGS (OPTIONAL)





    CONTACT INFORMATION (OPTIONAL)