Claris
Adverse Drug Experience
For Reporting Adverse Drug Experience fill in the form below:
Emergency Drug safety (24x7) contact Nos.: +44 (0) 7590558730, +44 (0) 07871849282
Fax: +44 (0) 2089476559
Fields marked with (*) are mandatory                                       
A. Patient Details
Name
Age*
  Sex*  
Date of Birth (DD/MM/YYYY)
Contact No
(Please add Country code and area code along with the dial in Number)
Email
B. Reporter Details
Name*
Contact No*
(Please add Country code and area code along with the dial in Number)
Email
Occupation
C. Adverse drug experience details
Describe the event*
(Max 500 Character)
Date of Event (DD/MM/YYYY)
Outcome Attributed to
Adverse event
Current Status
D. Suspect Drug Details
Name*
Batch No.
Expiry
Dose, Frequency & Route*
Attachment (Photographs, Reports etc)