Incident Reporting-Kisun Pharmaceutical-Drug products,Healthcare Services

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Suspected Adverse Drug Reaction Reporting Form

*Patient Name

Gender

Male

Woman

*Date of birth

Patient Contact Information

Area of occurrence

Medical institutions

Suspicion of Pharmaceutical Information (1)

*Generic Name

*Approval Number

*Dosage form

Specifications:

Suspicion of Pharmaceutical Information (2)

Generic name

Approval Number

Dosage form

Specifications

Suspicion of Pharmaceutical Information (3)

Generic name

Approval Number

Dosage form

Specifications

And include drug information (1)

Generic name

Approval Number

Dosage form

Specifications

And provide drug information (2)

Generic name

Approval Number

Dosage form

Specifications

Description of the process of adverse drug reactions

Image-based

Click to upload

Please upload a JPG image file smaller than 5MB.

File-based

Please upload files in RAR or ZIP format.

Adverse Reaction Name

Name of the Initial Reporter

Initial Reporter's Occupation

Report the name of the personnel

Contact information of the reporter

Does the initial reporter agree to PV staff following up for further communication?

Submit

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Pharmacovigilance

Incident Reporting

Tel:+86-576-88113608
Email:pv@kisunpharm.net

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