ADR Reporting

ADVERSE DRUG REACTION REPORTING FORM

For VOLUNTARY reporting of ADRs

INNOVATIVE LIFESCIENCES Helpline : +91 85588 11543 (10:00 AM to 6:00 PM, Monday-Saturday)

Gender/Sex

Male
Female
Other

Age / Age Group

Event Description

Description of Adverse Event / Side Effect / Any other experience such as Lack of Effect, Medication Error

Drug Use Detail

Suspect Drug details

Indication

Dosage / Unit / Frequency

Route

Treatment Dates

Treatment Start Date

Lot/Batch #

Treatment End Date

Expiry Date

Product Photo ( Batch Side )

Drop your file here or click here to upload You can upload up to 1 files.

Relevant Medical History (If Available)

Reporter Information

First Name

Last Name

Address

Address Line 1

City

Zip Code

Phone/Mobile

Relationship with Patient

Address Line 2

State

Country

Email *

Are you also the patient

Name

If you prefer to submit your report by mail, please download the reporting form and send the completed form to the address below.

Innovative Lifesciences Pvt. Ltd.

Registered Office: SCO-4, 2nd Floor, Swastik Vihar, Mansa Devi Complex, Sector 5, Panchkula, Haryana – 134109
Phone: +91 85588 11543
Email: innovativegroupcompanies@gmail.com

Adverse Event Reporting

To report an adverse event, please contact our Pharmacovigilance team using the contact details provided above. If additional information is required, our team will get in touch with you. We are committed to monitoring product safety and handling all reports in accordance with applicable pharmacovigilance regulations.

Who Can Report?

Healthcare Professionals (Doctors, Dentists, Nurses, Pharmacists, etc.)
Patients, Caregivers, Relatives, or Consumers

Confidentiality

All personal and medical information provided will be kept strictly confidential and used only for pharmacovigilance and regulatory purposes, in accordance with our Privacy Policy.