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Name^*

Location^*

Contact No.^*

Email ID ^*

Occupation

Relationship with Patient (if any) : Patient/Self Doctor/Healthcare Provider Family Member/Friend

Adverse Reaction Product Problem

Product Name^*

Dosage Last Taken^*

Still on Therapy?^* Yes No

Prescribed Lot No./Batch No. & Exp Date

Product Source

Prescribed^* Yes No

Other medicinal products (if any) excluding treatment of reaction (Name, Dose, Frequency, Route and Therapy Dates)

Patient Name^*

Age^*

Sex^* Male Female Pregnant Female

Contact No.^*

Location^*

Date of Event Onset^*

Describe here^*

Date of Improvement of Problem

Non serious Death Life Threatening Hospitalization Disability Birth Defect

Outcome^* Fatal Recovering Recovered Not Recovered Other

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Umesh Modi Group
1400, Modi Tower
98, Nehru Place, New Delhi-110019