Drug Safety - Mundipharma

Country*

Contact Information

Email*

Phone number*

Request Information

Request Type*

Product Quality
Adverse Drug Reactions

Product Type*

Trade name of the product*

Manufacturer*

Batch Number

Batch Number*

Manufacturing Date*

End Date*

Gender*

Male
Female

Description*

Attached File (PDF,IMG)*

Suspected Drugs Info (Optional)

Suspected Drug 1

Yes

Trade Name*

Strength*

Start Date*

Drug Use End Date*

Purpose of Use*

Suspected Drug 2

Yes

Trade Name*

Strength*

Start Date*

Drug Use End Date*

Purpose of Use*

Suspected Drug 3

Yes

Trade Name*

Strength*

Start Date*

Drug Use End Date*

Purpose of Use*

Patient Information (Optional)

Full Name

Medical Record Number

Age

Birth Day

Height (cm)

Weight (kg)

Product Details (Optional)

Product Type

Batch Number

Manufacturing Date

Expiry Date

Generic Name

How did you obtain the medication

From the pharmacy with a prescription
From the pharmacy without a prescription
From other stores (not a pharmacy)

Name and address of the store or pharmacy from which the medication was dispensed

Name

Address

DosageForm

Route

Purpose of Use

Strength*

Did you stop using the medication?

Yes
No

Start 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 Ended

Yes
No

Date

Current Patient Status

Did you inform the doctor or pharmacist of these adverse event?

Yes
No
Unknown

If Yes, Did he/she fil an adverse event reporting form?

Yes
No
Unknown

Can we obtain further information from your treating physician

Yes
No

If yes, please provide us with the communication information of the treating physician

Name

Hospital

Phone Number

Concomitant Drugs (Optional)

Drug 1

Yes

Trade Name

Start Date

End Date

Purpose Of Use

Drug 2

Yes

Trade Name

Start Date

End Date

Purpose Of Use

Drug 3

Yes

Trade Name

Start Date

End Date

Purpose Of Use

Contact Information (Optional)

Name

Professional

Region

Organization Info

Patient Relation

Consent Form

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”):

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.

KSA

UAE

Report Form

Contact Information

Request Information

Suspected Drugs Info (Optional)

Patient Information (Optional)

Product Details (Optional)

Side Effect (Optional)

Concomitant Drugs (Optional)

Contact Information (Optional)

Consent Form