Next Wave India | Pharmacovigilance

Report Adverse Event

Reporter Details

Full Name *

Occupation

Telephone Number *

Email Address

Apartment/House/Plot Number

Street Name

Landmark

Pin Code

City

State/Province

Country*

If reporter is the patient:

Yes

Patient Details

Name*

Date of Birth

Gender *

Telephone Number

Email Address

Suspect Drug Details

Name of OPES drug*

Batch no.

Expiry date

Dose

Frequency

Start date

Stop date

Adverse Event Details

Description of event *

Intensity:

Severe

Moderate

Mild

Note:

Fields marked with “*” are mandatory and must be filled in before submitting

You may also send us Adverse Event information by completing the form below and sending it to the address provided above.

Download AE Form

Rampur Ghat Road, Paonta Sahib, Distt. Sirmour, Himachal Pradesh, INDIA-173025
+91-1704-223215
info@nextwaveindia.in

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