Patient / Consumer Adverse Event Form
Pharmacovigilance & Patient Safety System
Reporting Region
Select Country
Zimbabwe
South Africa
Botswana
Namibia
1. Patient Information
Select Sex
Male
Female
Other
2. Adverse Event
3. Suspected Drug(s)
4. Other Medicines
Medicine
Strength & Dose
Route
Start
Stop
X
+ Add Medicine
5. Other Risk Factors
6. Reporter Details
Submit Patient Report