Contact Information

    PHARMACARE PREMIUM will contact you or your HCP (Health Care Professional) for further information if required.

    PLEASE COPY AND PASTE THE BELOW GUIDELINE AND USE TO FILL OUT THE COMMENTS SECTION:

    ADVERSE DRUG REACTION DETAILS :

    PERSONAL DETAILS  

    – Age, Sex, Weight, Race, Area

    DATE OF EVENT            

    – Date occurred, Date detected

    LOCATION OF EVENT     

    – Place occurred (Home / Hospital / Clinic / Nursing Home / Other)

    SUSPECTED MEDICINE

    – Trade Name, Active Ingredient, Manufacturer

    – Strength, Form, Batch no

    – Dosage, Frequency, Route

    – Prescribed for, Date started, Date stopped

    ADVERSE DRUG REACTION

    – Details of side effect, Date started, Date stopped

    OTHER MEDICINES USED (Including herbal and over the counter)

    – Trade Name, Active Ingredients, Manufacturer

    – Dosage, Prescribed for, Date started, Date stopped

    ADDITIONAL INFORMATION

    – Allergies, Pregnancy, Liver Disease, Kidney Disease, Other illnesses

    If you are reporting a side effect as a Patient, please provide full contact details for your Health Care Professional.

    PRODUCT FEEDBACK DETAILS :

    MEDICINE CONCERNED

    – Trade Name, Active Ingredient, Manufacturer

    – Strength, Form, Batch no

    DATE OF EVENT 

    – Date prescribed, Date detected

    DETAILS OF DEFECT             

    – Describe full details of state of product

    SOURCE OF PRODUCT

    -Please provide full contact details for your Health Care Professional