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Adverse Event Reporting
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NAME OF ENCORE LIMITED PRODUCT
*
The Product that you found any anamoly or adverse effect.
NATURE OF EVENT
ADVERSE/SIDE EFFECT
PRODUCT COMPLAINT (E.G. DEFECTS/MALFUNCTIONS)
PATIENT NAME
*
First
Last
GENDER
*
MALE
FEMALE
AGE
*
Date Of Birth
*
PREGNANT
*
SELECT ONE OPTION
YES
NO
EVENT DESCRIPTION
*
DESCRIPTION OF ADVERSE EVENT / SIDE EFFECT / ANY OTHER EXPERIENCE SUCH AS LACK OF EFFECT, MEDICATION ERROR
Suspect Drug details(Unit dose/strength & Form)
*
Dosage/ Unit/ Frequency
*
Route
*
TREATMENT START DATE
*
TREATMENT END DATE
*
Lot/Batch #
*
Expiration Date
*
RELEVANT MEDICAL HISTORY (IF AVAILABLE)
Reporter Full Name
*
Reporter Address
Reporter Country
*
Reporter Email
*
Reported Phone number
*
Are you also the patient?
*
Yes
No
Relationship with Patient
*
Send
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