Adverse Drug Report Form

Patient Information ?
Event Description ?
Drug Use Detail ?
Suspect Drug details(Unit dose/strength & Form)   Indication   Dosage/ Unit/ Frequency   Route
1.
 
 
 
2.
 
 
 
Treatment Dates
* Start Date * End (or Ongoing) * Lot/Batch # * Expiration Date
1.
 
 
 
2.
 
 
 
Reporter Information

If you would like to send us information by post, please download the form here and mail to the following address:

 

Department of Medical Service
FDC Limited
C-3, Sky vistas 106-A,
J. P. Road, D. N. Nagar,
near versova police station,
next to barfiwala college,
Andheri (West),Mumbai- 400 053
Maharashtra, India.
Tel :022-30719259

E-Mail: drug.safety@fdcindia.com