ADVERSE DRUG REACTION REPORTING FORM

For VOLUNTARY reporting of ADRs

Voizmed Pharmacovigilance Helpline : +91-8814892777‬ (10:00 AM to 6:00 PM, Monday-Saturday)

Adverse Event Reporting

Patient Information

Name or Initials

Gender/Sex

Male

Female

Other

Age / Age Group

Event Description

Description of Adverse Event / Side Effect / Any other experience such as Lack of Effect, Medication Error

Drug Use Detail

Suspect Drug details	Indication	Dosage / Unit / Frequency	Route

Treatment Dates

Treatment Start Date

Lot/Batch #

Product Photo ( Batch Side )

Upload File

Treatment End Date

Expiry Date

Relevant Medical History (If Available)

Reporter Information

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Phone/Mobile

Relationship with Patient

Are you also the patient

Yes

I accept that all enquiries submitted to "Adverse Event Reporting" are sent to Voizmed global pharmacovigilance team, headquartered in India. I accept that my personal data are shared with the relevant local team. I accept the Voizmed general Privacy Policy, described here

Our Locations

Important Links

Pharmaceutical Formulations

Helpline Numbers

Director Desk:neerajgiri@voizmed.com Mail us @ – voizmed@gmail.com

Monday – Saturday 10:00am -6:00pm