Phone:
+880 241090491
Email:
info@c2cpharma.com.bd
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Brand Name
Generic Name
Therapeutic Class
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Pharmacovigilance
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First Name (Person who is filling up this form)
*
Surname
*
Email
Mobile No
*
Qualification
*
Doctor
Other healthcare professional
Consumer
Address
Postcode
City
Country
*
Relationship to the patient
Patient name (person who experienced the adverse event)
Hospital name
Patient address
Patient Contact number
*
Age
*
Weight (kg)
Gender
*
Male
Female
Others
Pregnancy
Yes
No
Unknown
Brand name of the medicinal product
*
Suspected brand name of C2C Pharma Ltd
Generic name
*
Suspected generic name of C2C Pharma Ltd
Dosage form
*
Strength
*
Indication
Suspected generic name of C2C Pharma Ltd
When was the medicine started?
dd/mm/year
When was the medicine stopped?
dd/mm/year
How many unit medicines are taken?
Batch number
*
Other medicines taken
*
Adverse event description
When did the adverse event start?
dd/mm/year
Has the adverse event stopped?
Yes
No
Unknown
If Yes, on what date?
dd/mm/year
How bad was the adverse event?
Mild
Moderate
Severe
How is the adverse event now?
Mild
Moderate
Severe
Any other relevant history
Including pre-existing medical conditions, allergies, pregnancy, smoking, alcohol use, liver or kidney problems, hypersensitivity, history of ADRs, etc.
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