Drug Safety Report

For reporting of adverse events, safety information or safety concerns.

Date of Report/ Date of awareness/ Day zero:

Requestor Details:

Requestor Name

Requestor Email address (required)

Requestor Phone

Reporter Details:

Name / Initials *

Reporter Type*

Patients Details:

Patient Initials *

Patient age *

Patient gender*

Product Details:

Name of product *

Dosage taken / strength

Date of administration (start date)

Action taken with regards to the products / Stop date

Adverse event or safety information:

Description of event *

Date of onset of event

Outcome of the adverse event

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