Report of suspected adverse drug reactions
Please fill in the form below.
Patient details
Patient initials
Sex
Male
Female
Date of birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Suspected drug(s) vaccine
Trade Name
Dosage
Route of administration
Date started
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date stopped
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Indications
Suspected reactions
Details
Date of onset
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Duration of action
Additional information (Medical history, other medications, known allergies, suspected drug interaction)
Reporter's details (Name and professional address)
Phone Number
-
International code
Phone Number
Email
example@example.com
Report will be sent to the National Pharmacovigilance Committee
10th Floor, Emmanuel Anquetil Building Port Louis
Submit Form
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