Report Form Country*Select your countryKSAUAEContact InformationEmail* Phone number*Request InformationRequest Type*Product QualityAdverse Drug ReactionsProduct Type*DrugVaccineHerbal ProductCosmeticDiagnosticsOtherTrade name of the product*Manufacturer*Batch NumberBatch Number*Manufacturing Date* End Date* Gender*MaleFemaleDescription*Attached File (PDF,IMG)*Accepted file types: pdf, jpg, gif, png, jpeg.Suspected Drugs Info (Optional)Suspected Drug 1 Yes Trade Name*Strength*SelectMgmg/kgkgGμgngpgμg/kgmg/m2μg/m2LmlμlBqGBqMBqKbqCiMCiμCiNCiMolMmolμmolIuKiuMiuiu/kgMeq%GttDFStart Date* Drug Use End Date* Purpose of Use*Suspected Drug 2 Yes Trade Name*Strength*SelectMgmg/kgkgGμgngpgμg/kgmg/m2μg/m2LmlμlBqGBqMBqKbqCiMCiμCiNCiMolMmolμmolIuKiuMiuiu/kgMeq%GttDFStart Date* Drug Use End Date* Purpose of Use*Suspected Drug 3 Yes Trade Name*Strength*SelectMgmg/kgkgGμgngpgμg/kgmg/m2μg/m2LmlμlBqGBqMBqKbqCiMCiμCiNCiMolMmolμmolIuKiuMiuiu/kgMeq%GttDFStart Date* Drug Use End Date* Purpose of Use*Patient Information (Optional)Full NameMedical Record NumberAgeBirth Day Height (cm)Weight (kg)Product Details (Optional)Product TypeDrugVaccineHerbal ProductCosmeticsDiagnosticOtherBatch NumberBatch NumberManufacturing Date Expiry Date Generic NameHow did you obtain the medicationFrom the pharmacy with a prescriptionFrom the pharmacy without a prescriptionFrom other stores (not a pharmacy)Name and address of the store or pharmacy from which the medication was dispensedNameAddressDosageFormSelectTabletCapsulesSyrupTabletChewable TabletCoated TabletSustained release TabletDispersible TabletSublingual TabletEffervescent TabletPelletCapsulesSustained Release capsuleSyrupOral SolutionSuspensionElixirPowder for SuspensionLiquid for dissolution of antibioticsOral DropsPowderGranulesSachetsVial/Ampoulesintravenous injectionintramuscular injectionsubcutaneous injectionrefilled syringecartridgeSolution for InjectionSolution for InfusionInhalerSprayAerosolsNebulizersRota disc inhalersEye dropsEar dropsNasal DropsEye washCreamOintmentGelTopical solutionShampooSoapPatchesimplantsLotionTincturesSuppositoriesEnemaRectal creamRectal ointmentRectal tubesVaginal tabletVaginal creamVaginal ovulesVaginal washVaginal doucheVaginal ringpessaryMouth WashMouth gargleLozengesWaferfatty ointmentNail LacquerunknownotherRouteSelectOralPurpose of UseStrength*SelectMgmg/kgkgGμgngpgμg/kgmg/m2μg/m2LmlμlBqGBqMBqKbqCiMCiμCiNCiMolMmolμmolIuKiuMiuiu/kgMeq%GttDFDid you stop using the medication?YesNoStart Date Expiry Date Side Effect (Optional)Date of Event Started Seriousness of ADR Died Life Threatening Permanent Disability Hospitalization Prolonged Hospitalization More Than 24 Hr Congenital Anomaly Required Intervention to Prevent Permanent Impairment / Damage Other Date of Event EndedYesNoDate Current Patient StatusRecoveredNot ImprovedDeterioratedDid you inform the doctor or pharmacist of these adverse event?YesNoUnknownIf Yes, Did he/she fil an adverse event reporting form?YesNoUnknownCan we obtain further information from your treating physicianYesNoIf yes, please provide us with the communication information of the treating physicianNameHospitalPhone NumberConcomitant Drugs (Optional)Drug 1 Yes Trade NameStart Date End Date Purpose Of UseDrug 2 Yes Trade NameStart Date End Date Purpose Of UseDrug 3 Yes Trade NameStart Date End Date Purpose Of UseContact Information (Optional)NameProfessionalSelectPhysicianPharmacistLawyerOther health care professionalNurseConsumerOtherRegionRiyadhQassemMaccaNorth BordersNajranHailJazanTaboukEast RegionsMadinahAseerJoufBahahOtherRegionAbu DhabiDubaiSharjahAjmanUmm Al-QuwainFujairahRas Al KhaimahAl-AinOtherOrganization InfoSelectPatient RelationConsent FormIn compliance with Mundipharma Near East GmbH (“Mundipharma”) policy and applicable Saudi laws, Mundipharma seeks your consent to collect and use your Personal Data (as defined below) and to disclose such Personal Data to its affiliated offices. By signing this Consent Form, I hereby authorize Mundipharma and its representatives to collect, store, use, process, transfer and disclose (to affiliates of Mundipharma and competent authorities only) the following personal data (“Personal Data”): Contact details such as full name, address, phone number and email address Adverse event details (Other) you need to add any other purposes for the collection and processing of data The purpose of collection and use of the Personal Data is as follows: To receive adverse events in compliance with applicable Saudi laws Process adverse events and investigate them in compliance with applicable Saudi laws In compliance with Mundipharma Middle East FZ-LLC (“Mundipharma”) policy and applicable UAE laws, Mundipharma seeks your consent to collect and use your Personal Data (as defined below) and to disclose such Personal Data to its affiliated offices. By signing this Consent Form, I hereby authorize Mundipharma and its representatives to collect, store, use, process, transfer and disclose (to affiliates of Mundipharma and competent authorities only) the following personal data (“Personal Data”): Contact details such as full name, address, phone number and email address Adverse event details (Other) you need to add any other purposes for the collection and processing of data The purpose of collection and use of the Personal Data is as follows: To receive adverse events in compliance with applicable UAE laws Process adverse events and investigate them in compliance with applicable UAE laws Consent* I agree to the following:*I understand that my consenting to the use and disclosure of my Personal Data is voluntary and it can be withdrawn by me at any time by contacting Mundipharma at meadrugsafety@mundipharma.ae informing them of such withdrawal. I understand that my consenting to the use and disclosure of my Personal Data is voluntary and it can be withdrawn by me at any time by contacting Mundipharma at meadrugsafety@mundipharma.ae informing them of such withdrawal. KSAUAE
In compliance with Mundipharma Near East GmbH (“Mundipharma”) policy and applicable Saudi laws, Mundipharma seeks your consent to collect and use your Personal Data (as defined below) and to disclose such Personal Data to its affiliated offices.
By signing this Consent Form, I hereby authorize Mundipharma and its representatives to collect, store, use, process, transfer and disclose (to affiliates of Mundipharma and competent authorities only) the following personal data (“Personal Data”):
The purpose of collection and use of the Personal Data is as follows:
In compliance with Mundipharma Middle East FZ-LLC (“Mundipharma”) policy and applicable UAE laws, Mundipharma seeks your consent to collect and use your Personal Data (as defined below) and to disclose such Personal Data to its affiliated offices.
I understand that my consenting to the use and disclosure of my Personal Data is voluntary and it can be withdrawn by me at any time by contacting Mundipharma at meadrugsafety@mundipharma.ae informing them of such withdrawal.