pharmacovigilance
 

Please complete the below form in a much detail as possible so that information can be passed onto relevant Manufacturer.  This form should only be used by products supplied by Alston Garrard & Co. Ltd:

Patient Name:
Patient Date of Birth:
Age:
Sex:
male
female
Reaction Date:
Country where reaction took place:
Full Description of Reaction(s):
Did Reactions Abate After Stopping Drug?
Y N
Suspected Drug Name:
Suspected Drug Strength:
Daily Dose:
Route(s) of Administration:
Name of Manufacturer:
Product Batch Number:
Where was Product Supplied From (Pharmacy, Wholesaler, Supermarket):
Date of Form Submission:
Report Received From (Name, Address & Contact Number):


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