Report a possible side effect

In case of a medical emergency, please contact your local HCP for further assistance.

At Cipla we take the safety of our patients and consumers very seriously. We know that side effects can happen but it is not always possible to predict who will get them. For this reason, it is vital for us to continuously monitor the safety of our products. By hearing about your experiences and others like you we are able to offer the best possible advice to those using Cipla’s products.

Source

HospitalizedDeathLife ThreateningCongenital AnomalyNone of these


Reporter Details


Patient Information

MaleFemale

Date of Birth


Do you provide consent for further follow-up by our pharmacovigilance department regarding adverse event information that may be required?


Product Details

Did event/s reappear after drug was reintroduced?

Did event/s diminish after drug stopped/dose reduced?


Start Date of Use

Stop Date (if applicable)


Expiry Date

Manufactured Date

Action Taken


Adverse Event Details

Adverse Event/s Start Date

Adverse Event/s Stop Date (if applicable)

Outcome of Event

Was treatment received?


Concomitant Medication

Only answer below questions if YES

YesNo

Date Started

Stop Date (if applicable)


Other relevant information, if applicable:

captcha

Type the characters above