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TABROS PHARMA
Adverse Event Report Form
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* Indicates required question
Reporting Date
*
MM
/
DD
/
YYYY
Reporter Name
*
Your answer
Patient Name
*
Your answer
Reporter Contact Information (Cell Number or Email ID)
*
Your answer
Patient Gender
*
Male
Female
Patient Age (Only in years)
*
Your answer
Tabros Pharma Suspected Drug Name / Strength / Dosage Form
*
Your answer
Tabros Pharma Suspected Drug Batch #
*
Your answer
Adverse Event Details
*
Your answer
How is the patient’s condition?
*
Expired
Hospitalized
Requires Physician's Intervention (treatment/advice)
None of these
Life-threatening situation (need urgent care)
Birth defect
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