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The Form of Notification
1. Patient Information
Full name (initials)*
Age (years)*
Gender*
Select
Male
Female
Other
Contact details*
Additional information (comorbidities, pregnancy)
2. Information about suspected drug
Suspected drug*
Drug batch*
Dosage form*
Manufacturer*
Were other medicines also taken (name, dosage, method, period)*
3. Description of adverse reaction/lack of efficacy
Describe your problem in as much detail as possible*
4. Reporter Information
Full name (surname, first name, patronymic)*
Status*
Select
Doctor
Pharmacist
Patient
Other
Date of receipt of information*
Country, city*
+91
5. Doctor and healthcare institution information
Doctor’s full name*
Specialty*
+91
Healthcare institution address*
*fields are required
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