Pharmacovigilance

Please complete the form in as much detail as possible so that information can be passed onto relevant supplier. This form should only be used by products supplied by Alston Garrard & Co. Ltd.

Step 1 of 3

Details of Person Submitting Form
Profession
Name*
First Last
Email
Address
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Details of Drug
Suspected Drug Name
Suspected Drug Strength
Daily Dose
Route of Administration
Name of Manufacturer
Product Batch Number
Product Supplied From

Details of Patient
Name
First Last
Contact Telephone No
Please complete one of the following three options
- Date of Birth
- Age
- Age Group
Date of Birth
Date Format: DD slash MM slash YYYY
Age
Please enter a number from 0 to 150.
Age Group
Gender
Country Where Reaction Took Place
Full Description of Reaction(s): (Including outcome, relevant medical history and other medications taken)
Reaction Date
Date Format: DD slash MM slash YYYY
Did Reactions Abate After Stopping Drug?
Additional Comments
CAPTCHA

Delivering a healthier world.

Step 1 of 3

Details of Person Submitting Form

Details of Drug

Details of Patient

Contact us