Viribus | ADR Reporting

ADVERSE DRUG REACTION REPORTING FORM

For VOLUNTARY reporting of ADRs

Viribus Pharmacovigilance Helpline : +91-9915765565‬ (10:00 AM to 6:00 PM, Monday-Saturday)

Adverse Event Reporting

Patient Information

Name or Initials

Gender/Sex

Male

Female

Other

Age / Age Group

Event Description

Description of Adverse Event / Side Effect / Any other experience such as Lack of Effect, Medication Error

Drug Use Detail

Suspect Drug details	Indication	Dosage / Unit / Frequency	Route

Treatment Dates

Treatment Start Date

Lot/Batch #

Product Photo ( Batch Side )

Upload File

Treatment End Date

Expiry Date

Relevant Medical History (If Available)

Reporter Information

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Phone/Mobile

Relationship with Patient

Are you also the patient

Yes

I accept that all enquiries submitted to "Adverse Event Reporting" are sent to Voizmed global pharmacovigilance team, headquartered in India. I accept that my personal data are shared with the relevant local team. I accept the Voizmed general Privacy Policy, described here

If you would like to send us information by post, please download the form and mail to the following address:

Viribus Pharmacovigilance Department
Viribus Healthcare, S.C.O 518, Motor Market, Manimajra (Chandigarh)-160101

Toll Free Number : +91-9915765565
viribushealthcare@gmail.com

To report adverse events, we recommend you to use the email address viribushealthcare@gmail.com. If more information specific to your Country is required, you may also navigate to the Worldwide tab available on the website.

Viribus Healthcare has a strong commitment to manufacturing quality products. A comprehensive adverse event reporting database is maintained in order to ensure compliance regulations are met globally. Please help us by filling the form below in the event of adverse reactions. The information generated on the basis of these reports helps in continuous assessment of the benefit-risk ratio of medicines.

Who can report:

Any health care professional (Doctors, Dentists, Nurses, Pharmacists,Patients etc)
Non healthcare professional (Patient, relative, friend, etc)

Confidentiality:

The patient’s identity is held in strict confidence and protected to the fullest extent. The company shall not disclose the reporter’s identity in response to a request from the public.