For product complaints or reporting on adverse events, please call us on below number or send the details at below email id.

QUERY FORM

For product complaints or reporting on adverse events, please send the details at below email id.

globaldrugsafety@akums.in

Confidentiality: The patient's identity is held in strict confidence and protected to the fullest extent. The company shall not disclose the reporter’s identity in response to a request from the public.

All asterisk (*) fields are mandatory to fill

PATIENT INFORMATION

Your Name*

Date of Birth*

Gender*

Contact No.

Email Id

Reporting for/by*
SelfPhysician/PrescriberOthers

REPORTER INFORMATION

Name*

Contact No.*

Email*

REPORTER INFORMATION

Specify Relationship

Name*

Contact No.*

Email*

SUSPECTED ADVERSE REACTION

Event/Reaction Term (Eg: Headache, Vomiting etc)*

Event/Reaction Start Date*

Event/Reaction Stop Date*

Onset Duration Time*

Seriousness of the reaction*
NoYes

Serouisness Type

Describe Event/Reaction with treatment details, if any

Outcomes*

Additional Supporting documents

SUSPECT DRUG INFORMATION

S.No.	Name (Brand/Generic)*	Batch No. / Lot No.	Dose Used	Route Used	Frequency(OD, BD etc.)	Expiry date	Therapy Start date	Therapy End date	Indication (Medicine used for)

Action Taken:

Event abated after use stopped or dose reduced:

Event reappearedafter reintroduction :

Relationship of adverse event with drug:

CONCOMITANT MEDICATION (S)

Name (Brand/Generic)*

Dose used*

Route used*

Daily Dose (s)*

Therapy Start Date*

Therapy End Date*

Indication*

RELEVANT MEDICAL HISTORY/LAB TESTS

ADDITIONAL SUPPORTING DOCUMENTS

I accept that all enquiries related to Adverse Event Reporting are sent to Akums Pharma global Pharmacovigilance team, headquartered in India. I accept Akums Pharma general Privacy Policy, described above and my personal data are shared with the relevant team.

If you would like to send us information via e-mail, Please download the ADR form below and mail it to globaldrugsafety@akums.in

Download Adverse Event Reporting Form