Adverse - India

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 Event / Product Complaint Query Form

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

    Patient Information







    2

    Suspected Adverse Reaction









    PDF only

    3

    Suspect Drug Information

    #

    Name (Brand / Generic)

    Batch / Lot No.

    Dose Used

    Route Used

    Frequency

    Expiry Date

    Therapy Start

    Therapy End

    Indication

    1

    2

    3

    4

    5





    4

    Concomitant Medication(s)








    5

    Relevant Medical History / Lab Tests

    6

    Additional Supporting Documents

    PDF only


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

    Download Adverse Event Reporting Form