Report an Adverse Event English

Report an Adverse Event

English | Arabic

CONTACT INFORMATION

Email*
Mobile*

REQUEST INFORMATION

Request Type*

Is Drug Effective YesNo

Trade Name, Strength

Dosage Form

Generic Name

Registration Number

Batch Number

Manufacturing Date

Expiration Date

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)

Name and address of the store or pharmacy from which the medication was dispensed

Purpose of Use

Gender MaleFemale

Description

Attached File (PDF,IMG)

SUSPECTED DRUGS INFO (OPTIONAL)

Suspected Drugs

Start Date
End Date
Purpose of Use

PATIENT INFORMATION (OPTIONAL)

Full Name
Date Of Birth
Height (cm)
Weight (kg)

PRODUCT DETAILS (OPTIONAL)

Generic Name

How did you obtain the medication

Name and address of the store or pharmacy from which the medication was dispensed
Purpose of Use
Strength
Start Date
Did you stop using the medication? YesNo

SIDE EFFECT (OPTIONAL)

Date of Event Started

Seriousness of ADR

Date of Event Ended
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 YesNoIf yes, please provide us with the communication information of the treating physician