PHARMACOVIGILANCE REPORT FORM

This form aims to collect information regarding adverse drug reactions or unwanted drug interactions that may occur when using medications. This is part of our efforts to support and strengthen pharmacovigilance systems and ensure the highest levels of medication safety for patients.
Your participation in reporting any suspected cases contributes effectively to monitoring medication safety, improving the quality of healthcare, and taking the necessary corrective actions when needed.
All information entered in this form will be treated with strict confidentiality and used for scientific and regulatory purposes only.
Please complete the form as accurately as possible, as accurate data helps in better case analysis and informed decision-making.

All data in this form is subject to confidentiality agreements and will not be disclosed to any party other than the competent and concerned authorities.

Governorate*

All data in this form is subject to confidentiality agreements and will not be disclosed to any party other than the competent and concerned authorities.

Please let us know who you are

Informant's information

Doctor
Pharmacist
Patient

All data in this form is subject to confidentiality agreements and will not be disclosed to any party other than the competent and concerned authorities.

Complications Information Page

Name*

Phone Number*

Email*

Gender*

Age*

The product causing the complications*

Date of onset of complications*

Date of onset of complications

List the most significant complications that appeared*

Product images including expiry date and batch number*

Product images including expiry date and batch number

Was the diagnosis made by a medical professional?

Yes
No

Is the patient taking any other medications? (Please mention)

All data in this form is subject to confidentiality agreements and will not be disclosed to any party other than the competent and concerned authorities.

I, the whistleblower, declare that all information provided in this form is true and accurate to the best of my knowledge and belief, and has been submitted in good faith and solely for the purpose of reporting a pharmacovigilance-related matter.

I further undertake that I will provide any additional information that becomes available later to the relevant authority upon request, understanding that this data will be used for pharmacovigilance purposes in accordance with established regulations, while maintaining the confidentiality of my personal information.

I acknowledge the accuracy and validity of the information provided, and I agree to its use for pharmacovigilance purposes only.