Personal info of the reporter
Health Care Practitioner
Country of Residence
Information of the Person that experienced the Adverse event
Age of the patient
Details of Product
Product Name (
Generic name & Strength
When was the product administered?
When was the Product Stopped?
Adverse Event Report in details
Physician's Details (If any)
In compliance to Personal Data Protection Rule by the International Standards of Data Protection,
ensures compliance of its staff and Respondents with strict standards of security and confidentiality.