This form is meant for members of the public and patients to report adverse drug reactions, adverse events following vaccination, incidents involving medical devices or poor quality medicinal products.
Health care professionals should register and submit reports after successfull authentication.

COA
DETAILS OF THE PERSON REPORTING
DETAILS OF THE PATIENT
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If selected, year is mandatory.

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SIDE EFFECT
Select all side effects experienced
What were the signs of the side effect?
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POOR QUALITY MEDICINE
Select all issues with the medicine/device
Additional wrong things?
DETAILS OF THE MEDICINE/VACCINE/DEVICE THAT CAUSED THE REACTION
(Include all medications)
1 Name of Medicine/Vaccine/Device Manufacturer
When did you start taking/using the medicine/vaccine/device? When did you stop taking/using the medicine/vaccine/device? (dd-mm-yyyy)
Expiry date of the medicine/vaccine/device Where did you buy the medicine/vaccine/device?
Do you have pictures or documents that you would like to send to PPB? click on the button to add them:
# File Text Description
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