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

AKUMS INDIA

Toll free number- 1800-313-3363, Mail Us: indiadrugsafety@akums.in
All working days (Monday to Saturday) 9:00 AM to 6:00 PM

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 indiadrugsafety@akums.in

Download Adverse Event Reporting Form / प्रतिकूल घटना रिपोर्टिंग फॉर्म डाउनलोड करें

this form i want to add in page so what will be structure of template

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