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العربية
Home
About Us
Services
Products
Our Community
Contact Us
Contact Us
FAQ
Careers
Pharmacovigilance
Advanced natural
Home
About Us
Services
Products
Our Community
Contact Us
Contact Us
FAQ
Careers
Pharmacovigilance
Advanced natural
العربية
Home
>
Pharmacovigilance
> Report a Side Effect
Pharmacovigilance
Adverse Reaction Reporting Form
Reporting Purpose
We realize that filling this form requires time to complete, but reporting adverse drug reactions are indispensable for safe use of medication. The SFDA can judge the safety of medicinal products in Saudi Arabia only if sufficient information is provided. Confidentiality: Reporter's and patient's identity are held in strict confidence by SFDA and protected to the fullest extent of the law, information provided by the reporter will be strictly protected and will not be used in any way against him
Contact Information
Full Name
(Required)
First
E-mail
(Required)
Mobile
(Required)
Request Information
Trade Name
(Required)
Choose trade Name
orianma ointment
vittaal gel
Gender
(Required)
برجاء تحديد الجنس
Male
Female
Are you pregnant?
Yes
No
Adverse Event Relevant test/Lab data and Dates
Suspected Drugs Info
Suspected Drugs name
(Required)
اختر الدواء المشتبه به
مرهم أورياما
فيتال جيل
Expiry date
DD slash MM slash YYYY
Drug start date
(Required)
DD slash MM slash YYYY
Purpose of use
Patient Information (Optional)
Full Name
First
Medical Record No
Birth date
MM slash DD slash YYYY
Age
Weight (Kg)
Height (Cm)
Product Details (Optional)
Did you stop using the medication?
Yes
No
How did you obtain the medication
From the pharmacy with a prescription
From the pharmacy without a prescription
From other stores (not a pharmacy)
Product Type
Drug
Vaccine
Herbal
Product
Cosmetic
Diagnostics
Other
Purpose of use
Side Effect (Optional)
Date of Event Ended
Yes
No
Date of Event Started
(Required)
DD slash MM slash YYYY
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
Current Patient Status
Fully recovered
In the process of improvement
He didn't get any better.
Unknown
Accompanying medicines
Medical History
Can we obtain further information from your treating physician?
(Required)
Yes
No
Did you inform the doctor or pharmacist of these adverse event?
Yes
No
Hospital
Physician Phone
Physician Name
Δ
