Adverse Event Reporting
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Reporter Details

Name of Reporter
LandLine Number
Mobile Number
City

Personal Information

Sex
Ageyour full name
Date of Birth

Do you provide consent for further follow-up by our pharmacovigilance department regarding adverse event information that may be required?

Product Details

Cipla Product/ Dosage
Dosage Frequency
Route of Administration
Indication/Use
Did event/s reappear after drug was reintroduced?
Did event/s diminish after drug stopped/dose reduced?
Start Date of Use
Stop Dateif applicable)
Batch No
Lot No
Adverse Event Detailsmore details
0 /
Adverse Event/s Start Date
Adverse Event/s Stop Dateif applicable
Please Specify treatment if YESmore details
0 /

Concomitant Medication

Only answer below questions if YESpick one!
Trade Name & Batch Noyour full name
Daily Dosage
Route
Date Started
Stop Dateif applicable
Indication
Other relevant information, if applicable:more details
0 /
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Address

Cipla Quality Chemical Industries Limited
Plot 1-7, 1st Ring Road, Luzira Industrial Park
P.O Box 34871, Kampala-Uganda

Telephone: +256 312 341 100
Email: info@ciplaqcil.co.ug