Online ADR Reporting Form

Online Application

Online ADR Reporting Form

Please enter your details below

Particulars of Patient

Enter a valid Name (Only Alphabets) Min 3 Characters
Enter gender
Enter Valid Date
 
Enter Weight (Only 3 digit Number up to 2 decimal places)

Details the Adverse Drug Reaction

Enter Valid Date

Enter Valid Date
 
Enter Description of ADR
Enter Outcome

Enter Valid Date

Suspected Drug Details

Enter a valid Name (Only Alphabets) Min 3 Characters
Enter a valid Indication (Only Alphabets) Min 3 Characters
 
Enter Amount (Only 9 digit Number up to 2 decimal places)
Enter Unit

Enter Valid Date
Enter a valid Frequency (Max 10 Characters)
Enter a valid Route (Max 256 Min 3 Characters)
Enter a valid Batch Number (Max 12 Min 3 Characters)
Enter a valid Duration (Max 8 Min 3 Characters)

Enter Valid Date

Details of Concomitant drugs

Enter a valid Name (Only Alphabets) Min 3 Characters
Enter a valid Indication (Only Alphabets) Min 3 Characters
 
Enter Amount (Only 9 digit Number up to 2 decimal places)
Enter Unit

Enter Valid Date
Enter a valid Frequency (Max 10 Characters)
Enter a valid Route (Max 256 Min 3 Characters)
Enter a valid Batch Number (Max 12 Min 3 Characters)
Enter a valid Duration (Max 8 Min 3 Characters)

Enter Valid Date

Other Relevant Information

Enter Example (Max 512 Min 3 Characters)

Applicant's Information

Enter a valid Name (Only Alphabets) Min 3 Characters
Enter a valid Email
Enter ISD code
Enter a valid Phone Number (Min 10 Max 12 Characters)
Enter occupation (Max 256 Min 3 Characters)

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