Report Side Effects Form (for Professionals)

Dear healthcare professional;


We realize that filling this form requires time to complete, but reporting adverse drug reactions are indispensable for safe use of medication. be sure reporter’s and patient’s identity are held in strict confidence by the company and protected to the fullest extent of the law, information provided by the reporter will be strictly protected and will not be used in any way against him  her.

This form can be used by: Physician, Pharmacist, Dentist, Nurses and Other healthcare providers.


Please fill the form carefully:

Patient details

Suspected & Concomitant Drug(s) Used

Adverse Drug Reaction

Outcome of ADR (Tick all applicable)

Action Taken

Seriousness of ADR (Tick all applicable)

Reporter Details