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ADR Reporting form: Healthcare Professionals

Suspected Adverse Drug Reporting Form
(For VOLUNTARY Reporting of Adverse Drug Reactions By HealthCare Professional)

Report Type:
A. Patient Information:
       
B. Suspected Adverse Reaction:
 

C. Suspected Medication(s):

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Indication Causality Assessment
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D. REPORTER (see confidentiality section on first page) 16. Name and Professional Address: