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Nature of event (Check all that apply) *

Adverse Event/Side EffectPregnancy/lactationOverdoseLack of efficacy MisuseAbuseProduct Complaint

Patient Information

Gender*

MaleFemaleOther

Event Description

Current Status / Outcome: (at the time of this report) *

Complete RecoveryOngoingRecoveringUnknownDied

Drug Use Detail*

Treatment Dates

Start Date *

End Date *

Expiry Date *

Reporter Information

Are you also the patient *

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