Adverse - Global

QUERY FORM

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

    Adverse Drug Reaction (ADR) / Adverse Event (AE) Reporting Form

    For product complaints or reporting on adverse events, please fill out the form below, or send the details directly to
    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

    1

    Type & Classification of Report




    2

    Patient Information








    3

    Adverse Event










    PDF only

    4

    Relevant Tests & Medical History



    5

    Suspected Medication(s)

    #

    Name (Brand / Generic)

    Batch / Lot No.

    Exp. Date

    Dose Used

    Route Used

    Frequency

    Start Date

    Stop Date

    Indication

    1

    2

    3

    4

    5





    6

    Concomitant Medication(s)


    7

    Reporter







    8

    Additional Supporting Documents

    PDF only — if any additional data, please attach with this form


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

    Download Adverse Event Reporting Form