Report Side Effect

To contact the Pharma pharmacovigilance department

Phone

+963942011192

+905314507568

Email

pv@e-revapharma.com

Location

Syria - Idlib

Patient Data

Full Name

Age

Gender

Male Female

Phone Number

Weight

Height

Side Effect Data

Side Effect Name

Name of the Medicine

Preparation Number *

Date of Onset of Side Effects

Date of End of Side Effect

Symptoms

Is side effect serious?

Yes No

The Action Taken:

Was the medication resumed?

Yes No

Other medications and dietary supplements taken by the patient:

Name of Medicine

Medication Dose