Designer Archives - Taevas Life Sciences

Report Date

Name*

Location*

Contact Number*

Email ID*

Occupation

Relationship with Patient (if any) : Patient/SelfDoctor/Healthcare ProviderFamily Member/Friend

Adverse ReactionProduct Problem

Product Name*

Dosage Last Taken*

Still on Therapy?* YesNo

Prescribed Lot No./Batch No. & Exp Date

Product Source

Prescribed YesNo

Other medicinal products (if any) excluding treatment of reaction (Name, Dose, Frequency, Route and Therapy Dates)

Patient Name*

Age*

Gender* MaleFemalePregnant Female

Contact No.*

Location*

Date of Event Onset*

Describe here*

Date of Improvement of Problem

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