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Adverse Reaction Reporting Form
Adverse Drug Reaction Reporting Form
for Consumers
Patient Information
Full Name
Address
Phone
E-mail
Suspected Drug Information
Brand Name
Dosage Form
Manufacturer
Indication for Suspected Drug
Was the suspected drug prescribed by a doctor?
Yes
No
Description of adverse reaction manifestations or indication of lack of efficacy
Reporter Information
Full Name
Address
Phone
E-mail
Information about the doctor and healthcare institution at the patient's residence where the adverse reaction or lack of efficacy was observed
Full Name
Address
Phone
Additional Information
Reset
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