Adverse Drug Reaction Reporting Form

A. Patient Information*

Patient Name

Date of Birth

Age

Gender
MaleFemaleOther

Weight (In Kg)

Relevant Medical History - Allergy with Medicines

Allergy with Medicines
HypertensionDiabetesPregnancyHepatic DysfunctionRenal Dysfunction

B. Medication Details*

Name of Meridian Drug

Batch No. / Lot No

Expiry Date

Disease / Disorder

Dosage

Medication consumed if more than prescribed dose

Route of administration of drug

Duration of Drug

Date started

Date stopped

Concomitant medications (If any)

C. Suspected Adverse Drug Reaction*

Event/Reaction start date (DD/MM/YYYY)

Event/Reaction end date (DD/MM/YYYY)

Description of adverse drug reactions in detail

D. Action taken after adverse reaction

Drug withdrawn Yes

Dose reduced Yes

E. Seriousness of the reaction

Manageable at home Yes

Life threatening reaction Yes

F. Outcome of reaction

Recovered Yes

Not Recovered Yes

Fatal Yes

G. Reporter Details

Name

Address

Pin Code

Country

Email *

Confirm Email *

Contact No *

Occupation

Relationship with patient

Date of report

I accept that all enquiries submitted to "Adverse Drug Reaction Reporting" which have been sent to the technical department of Meridian Enterprises Pvt. Ltd. based at Nariman Point, Mumbai, India. I accept that my personal data are shared with the relevant local team. I accept the privacy policy of Meridian Enterprises Pvt. Ltd., as described here by.

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If you would like to send us information by post, please download the form and mail to the following address:

Technical Department

Meridian Enterprises Pvt. Ltd

1108, Embassy Centre, Nariman Point,

Mumbai - 400 021, India.

Telephone No. (+91 22) 66084200