{"id":108,"date":"2026-08-07T11:44:55","date_gmt":"2026-08-07T11:44:55","guid":{"rendered":"https:\/\/innovativelifesciences.in\/adr\/?page_id=108"},"modified":"2026-08-07T13:09:40","modified_gmt":"2026-08-07T13:09:40","slug":"adr-reporting","status":"publish","type":"page","link":"https:\/\/innovativelifesciences.in\/adr\/","title":{"rendered":"ADR Reporting"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"108\" class=\"elementor elementor-108\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-02f6ab4 e-con-full e-flex wpr-particle-no wpr-jarallax-no wpr-parallax-no wpr-sticky-section-no wpr-column-slider-no wpr-equal-height-no e-con e-parent\" data-id=\"02f6ab4\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-82c29d8 better-wrapper elementor-widget elementor-widget-heading\" data-id=\"82c29d8\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">ADVERSE DRUG REACTION REPORTING FORM<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-e29f5f5 elementor-widget elementor-widget-heading\" data-id=\"e29f5f5\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">For VOLUNTARY reporting of ADRs<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-a677b38 elementor-widget elementor-widget-heading\" data-id=\"a677b38\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">INNOVATIVE LIFESCIENCES Helpline : +91 85588 11543 (10:00 AM to 6:00 PM, Monday-Saturday)<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-44baba6 e-con-full e-flex wpr-particle-no wpr-jarallax-no wpr-parallax-no wpr-sticky-section-no wpr-column-slider-no wpr-equal-height-no e-con e-parent\" data-id=\"44baba6\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-2e9db52 elementor-widget elementor-widget-shortcode\" data-id=\"2e9db52\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><div class=\"everest-forms\"><div class=\"evf-container default\" id=\"evf-117\"><form id=\"evf-form-117\" class=\"everest-form\" data-formid=\"117\" data-ajax_submission=\"0\" data-keyboard_friendly_form=\"0\" data-form_state_type=\"\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/adr\/wp-json\/wp\/v2\/pages\/108\"><div class=\"evf-field-container\"><input type=\"hidden\" id=\"_wpnonce117\" name=\"_wpnonce117\" value=\"db63e9536b\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/adr\/wp-json\/wp\/v2\/pages\/108\" \/><div class=\"evf-frontend-row\" data-row=\"row_1\" conditional_rules=\"[]\"><div class=\"evf-frontend-grid evf-grid-1\" data-grid=\"grid_1\"><div id=\"evf-117-field_fullname-container\" class=\"evf-field evf-field-text form-row validate-required\" data-required-field-message=\"This field is required.\" data-field-id=\"fullname\"><label class=\"evf-field-label\" for=\"evf-117-field_fullname\"><span class=\"evf-label\">Name of Drug<\/span> <abbr class=\"required\" title=\"Required\">*<\/abbr><\/label><input type=\"text\" id=\"evf-117-field_fullname\" class=\"input-text\" name=\"everest_forms[form_fields][fullname]\" placeholder=\"Name of Drug\" required><\/div><div id=\"evf-117-field_Bacx6YToqH-1-container\" class=\"evf-field evf-field-checkbox form-row\" data-field-id=\"Bacx6YToqH-1\"><label class=\"evf-field-label\" for=\"evf-117-field_Bacx6YToqH-1\"><span class=\"evf-label\">Nature of event (Check all that apply)<\/span> <\/label><ul id=\"evf-117-field_Bacx6YToqH-1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"evf-117-field_Bacx6YToqH-1_1\" class=\"input-text\" name=\"everest_forms[form_fields][Bacx6YToqH-1][]\" value=\"Adverse Event\/Side Effect\"  ><label class=\"everest-forms-field-label-inline\" for=\"evf-117-field_Bacx6YToqH-1_1\">Adverse Event\/Side Effect<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"evf-117-field_Bacx6YToqH-1_2\" class=\"input-text\" name=\"everest_forms[form_fields][Bacx6YToqH-1][]\" value=\"Pregnancy\/lactation\"  ><label class=\"everest-forms-field-label-inline\" for=\"evf-117-field_Bacx6YToqH-1_2\">Pregnancy\/lactation<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"evf-117-field_Bacx6YToqH-1_3\" class=\"input-text\" name=\"everest_forms[form_fields][Bacx6YToqH-1][]\" value=\"Overdose\"  ><label class=\"everest-forms-field-label-inline\" for=\"evf-117-field_Bacx6YToqH-1_3\">Overdose<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"evf-117-field_Bacx6YToqH-1_4\" class=\"input-text\" name=\"everest_forms[form_fields][Bacx6YToqH-1][]\" value=\"Lack of efficacy\"  ><label class=\"everest-forms-field-label-inline\" for=\"evf-117-field_Bacx6YToqH-1_4\">Lack of efficacy<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"evf-117-field_Bacx6YToqH-1_5\" class=\"input-text\" name=\"everest_forms[form_fields][Bacx6YToqH-1][]\" value=\"Misuse\"  ><label class=\"everest-forms-field-label-inline\" for=\"evf-117-field_Bacx6YToqH-1_5\">Misuse<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"evf-117-field_Bacx6YToqH-1_6\" class=\"input-text\" name=\"everest_forms[form_fields][Bacx6YToqH-1][]\" value=\"Abuse\"  ><label class=\"everest-forms-field-label-inline\" for=\"evf-117-field_Bacx6YToqH-1_6\">Abuse<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"evf-117-field_Bacx6YToqH-1_7\" class=\"input-text\" name=\"everest_forms[form_fields][Bacx6YToqH-1][]\" value=\"Product Complaint\"  ><label class=\"everest-forms-field-label-inline\" for=\"evf-117-field_Bacx6YToqH-1_7\">Product Complaint<\/label><\/li><\/ul><\/div><div id=\"evf-117-field_HjD3ssgo8y-2-container\" class=\"evf-field evf-field-html form-row\" data-field-id=\"HjD3ssgo8y-2\"><div id=\"evf-117-field_HjD3ssgo8y-2\" class=\"input-text\"><div style=\"background:#8f2829;color:#fff;padding:12px 20px;border-radius:8px;font-size:18px;font-weight:700;margin:20px 0\">\r\nPatient Information\r\n<\/div><\/div><\/div><div id=\"evf-117-field_HYw5Fr16Oc-3-container\" class=\"evf-field evf-field-text form-row\" data-field-id=\"HYw5Fr16Oc-3\"><label class=\"evf-field-label\" for=\"evf-117-field_HYw5Fr16Oc-3\"><span class=\"evf-label\">Name or Initials<\/span> <\/label><input type=\"text\" id=\"evf-117-field_HYw5Fr16Oc-3\" class=\"input-text\" name=\"everest_forms[form_fields][HYw5Fr16Oc-3]\" placeholder=\"Name or Initials\" ><\/div><\/div><\/div><div class=\"evf-frontend-row\" data-row=\"row_2\" conditional_rules=\"[]\"><div class=\"evf-frontend-grid evf-grid-2\" data-grid=\"grid_1\"><div id=\"evf-117-field_egNuJE6RnQ-4-container\" class=\"evf-field evf-field-radio form-row\" data-field-id=\"egNuJE6RnQ-4\"><label class=\"evf-field-label\" for=\"evf-117-field_egNuJE6RnQ-4\"><span class=\"evf-label\">Gender\/Sex<\/span> <\/label><ul id=\"evf-117-field_egNuJE6RnQ-4\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"evf-117-field_egNuJE6RnQ-4_1\" class=\"input-text\" name=\"everest_forms[form_fields][egNuJE6RnQ-4]\" value=\"Male\"  ><label class=\"everest-forms-field-label-inline\" for=\"evf-117-field_egNuJE6RnQ-4_1\">Male<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"evf-117-field_egNuJE6RnQ-4_2\" class=\"input-text\" name=\"everest_forms[form_fields][egNuJE6RnQ-4]\" value=\"Female\"  ><label class=\"everest-forms-field-label-inline\" for=\"evf-117-field_egNuJE6RnQ-4_2\">Female<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"evf-117-field_egNuJE6RnQ-4_3\" class=\"input-text\" name=\"everest_forms[form_fields][egNuJE6RnQ-4]\" value=\"Other\"  ><label class=\"everest-forms-field-label-inline\" for=\"evf-117-field_egNuJE6RnQ-4_3\">Other<\/label><\/li><\/ul><\/div><\/div><div class=\"evf-frontend-grid evf-grid-2\" data-grid=\"grid_2\"><div id=\"evf-117-field_zb2Mai7Y27-5-container\" class=\"evf-field evf-field-text form-row\" data-field-id=\"zb2Mai7Y27-5\"><label class=\"evf-field-label\" for=\"evf-117-field_zb2Mai7Y27-5\"><span class=\"evf-label\">Age \/ Age Group<\/span> <\/label><input type=\"text\" id=\"evf-117-field_zb2Mai7Y27-5\" class=\"input-text\" name=\"everest_forms[form_fields][zb2Mai7Y27-5]\" ><\/div><\/div><\/div><div class=\"evf-frontend-row\" data-row=\"row_3\" conditional_rules=\"[]\"><div class=\"evf-frontend-grid evf-grid-1\" data-grid=\"grid_1\"><div id=\"evf-117-field_vGC14CDwZo-6-container\" class=\"evf-field evf-field-html form-row\" data-field-id=\"vGC14CDwZo-6\"><div id=\"evf-117-field_vGC14CDwZo-6\" class=\"input-text\"><div style=\"background:#8f2829;color:#fff;padding:12px 20px;border-radius:8px;font-size:18px;font-weight:700;margin:20px 0\">\r\nEvent Description\r\n<\/div><\/div><\/div><div id=\"evf-117-field_8UjFPSYmWB-7-container\" class=\"evf-field evf-field-textarea form-row\" data-field-id=\"8UjFPSYmWB-7\"><label class=\"evf-field-label\" for=\"evf-117-field_8UjFPSYmWB-7\"><span class=\"evf-label\">Description of Adverse Event \/ Side Effect \/ Any other experience such as Lack of Effect, Medication Error<\/span> <\/label><textarea id=\"evf-117-field_8UjFPSYmWB-7\" class=\"input-text\" name=\"everest_forms[form_fields][8UjFPSYmWB-7]\"  ><\/textarea><\/div><div id=\"evf-117-field_TTFrNgfTWv-8-container\" class=\"evf-field evf-field-checkbox form-row\" data-field-id=\"TTFrNgfTWv-8\"><label class=\"evf-field-label\" for=\"evf-117-field_TTFrNgfTWv-8\"><span class=\"evf-label\">Current Status \/ Outcome: (at the time of this report)<\/span> <\/label><ul id=\"evf-117-field_TTFrNgfTWv-8\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"evf-117-field_TTFrNgfTWv-8_1\" class=\"input-text\" name=\"everest_forms[form_fields][TTFrNgfTWv-8][]\" value=\"Complete Recovery\"  ><label class=\"everest-forms-field-label-inline\" for=\"evf-117-field_TTFrNgfTWv-8_1\">Complete Recovery<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"evf-117-field_TTFrNgfTWv-8_2\" class=\"input-text\" name=\"everest_forms[form_fields][TTFrNgfTWv-8][]\" value=\"Ongoing\"  ><label class=\"everest-forms-field-label-inline\" for=\"evf-117-field_TTFrNgfTWv-8_2\">Ongoing<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"evf-117-field_TTFrNgfTWv-8_3\" class=\"input-text\" name=\"everest_forms[form_fields][TTFrNgfTWv-8][]\" value=\"Recovering\"  ><label class=\"everest-forms-field-label-inline\" for=\"evf-117-field_TTFrNgfTWv-8_3\">Recovering<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"evf-117-field_TTFrNgfTWv-8_4\" class=\"input-text\" name=\"everest_forms[form_fields][TTFrNgfTWv-8][]\" value=\"Unknown\"  ><label class=\"everest-forms-field-label-inline\" for=\"evf-117-field_TTFrNgfTWv-8_4\">Unknown<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"evf-117-field_TTFrNgfTWv-8_5\" class=\"input-text\" name=\"everest_forms[form_fields][TTFrNgfTWv-8][]\" value=\"Died\"  ><label class=\"everest-forms-field-label-inline\" for=\"evf-117-field_TTFrNgfTWv-8_5\">Died<\/label><\/li><\/ul><\/div><div id=\"evf-117-field_pPlQ6KWkBR-9-container\" class=\"evf-field evf-field-html form-row\" data-field-id=\"pPlQ6KWkBR-9\"><div id=\"evf-117-field_pPlQ6KWkBR-9\" class=\"input-text\"><div style=\"background:#8f2829;color:#fff;padding:12px 20px;border-radius:8px;font-size:18px;font-weight:700;margin:20px 0\">\r\nDrug Use Detail\r\n<\/div><\/div><\/div><\/div><\/div><div class=\"evf-frontend-row\" data-row=\"row_4\" conditional_rules=\"[]\"><div class=\"evf-frontend-grid evf-grid-4\" data-grid=\"grid_1\"><div id=\"evf-117-field_zu37YcE599-11-container\" class=\"evf-field evf-field-text form-row\" data-field-id=\"zu37YcE599-11\"><label class=\"evf-field-label\" for=\"evf-117-field_zu37YcE599-11\"><span class=\"evf-label\">Suspect Drug details<\/span> <\/label><input type=\"text\" id=\"evf-117-field_zu37YcE599-11\" class=\"input-text\" name=\"everest_forms[form_fields][zu37YcE599-11]\" ><\/div><\/div><div class=\"evf-frontend-grid evf-grid-4\" data-grid=\"grid_2\"><div id=\"evf-117-field_eU1Z5olyD6-12-container\" class=\"evf-field evf-field-text form-row\" data-field-id=\"eU1Z5olyD6-12\"><label class=\"evf-field-label\" for=\"evf-117-field_eU1Z5olyD6-12\"><span class=\"evf-label\">Indication<\/span> <\/label><input type=\"text\" id=\"evf-117-field_eU1Z5olyD6-12\" class=\"input-text\" name=\"everest_forms[form_fields][eU1Z5olyD6-12]\" ><\/div><\/div><div class=\"evf-frontend-grid evf-grid-4\" data-grid=\"grid_3\"><div id=\"evf-117-field_AsGZz2lQsJ-13-container\" class=\"evf-field evf-field-text form-row\" data-field-id=\"AsGZz2lQsJ-13\"><label class=\"evf-field-label\" for=\"evf-117-field_AsGZz2lQsJ-13\"><span class=\"evf-label\">Dosage \/ Unit \/ Frequency<\/span> <\/label><input type=\"text\" id=\"evf-117-field_AsGZz2lQsJ-13\" class=\"input-text\" name=\"everest_forms[form_fields][AsGZz2lQsJ-13]\" ><\/div><\/div><div class=\"evf-frontend-grid evf-grid-4\" data-grid=\"grid_4\"><div id=\"evf-117-field_gZmPs9MDsZ-14-container\" class=\"evf-field evf-field-text form-row\" data-field-id=\"gZmPs9MDsZ-14\"><label class=\"evf-field-label\" for=\"evf-117-field_gZmPs9MDsZ-14\"><span class=\"evf-label\">Route<\/span> <\/label><input type=\"text\" id=\"evf-117-field_gZmPs9MDsZ-14\" class=\"input-text\" name=\"everest_forms[form_fields][gZmPs9MDsZ-14]\" ><\/div><\/div><\/div><div class=\"evf-frontend-row\" data-row=\"row_5\" conditional_rules=\"[]\"><div class=\"evf-frontend-grid evf-grid-1\" data-grid=\"grid_1\"><div id=\"evf-117-field_IVhCPe8yGG-15-container\" class=\"evf-field evf-field-html form-row\" data-field-id=\"IVhCPe8yGG-15\"><div id=\"evf-117-field_IVhCPe8yGG-15\" class=\"input-text\"><div style=\"background:#8f2829;color:#fff;padding:12px 20px;border-radius:8px;font-size:18px;font-weight:700;margin:20px 0\">\r\nTreatment Dates\r\n<\/div><\/div><\/div><\/div><\/div><div class=\"evf-frontend-row\" data-row=\"row_6\" conditional_rules=\"[]\"><div class=\"evf-frontend-grid evf-grid-2\" data-grid=\"grid_1\"><div id=\"evf-117-field_05k0jjp0sJ-16-container\" class=\"evf-field evf-field-date-time form-row\" data-field-id=\"05k0jjp0sJ-16\"><label class=\"evf-field-label\" for=\"evf-117-field_05k0jjp0sJ-16\"><span class=\"evf-label\">Treatment Start Date<\/span> <\/label><input type=\"text\" id=\"evf-117-field_05k0jjp0sJ-16\" class=\"flatpickr-field input-text\" name=\"everest_forms[form_fields][05k0jjp0sJ-16]\" data-time-interval=\"15\" data-date-time=\"date\" data-mode=\"single\" data-locale=\"en\" data-date-format=\"Y-m-d\"  ><\/div><div id=\"evf-117-field_NMShk6jXfz-18-container\" class=\"evf-field evf-field-text form-row\" data-field-id=\"NMShk6jXfz-18\"><label class=\"evf-field-label\" for=\"evf-117-field_NMShk6jXfz-18\"><span class=\"evf-label\">Lot\/Batch #<\/span> <\/label><input type=\"text\" id=\"evf-117-field_NMShk6jXfz-18\" class=\"input-text\" name=\"everest_forms[form_fields][NMShk6jXfz-18]\" ><\/div><\/div><div class=\"evf-frontend-grid evf-grid-2\" data-grid=\"grid_2\"><div id=\"evf-117-field_qBRKKOtBAp-17-container\" class=\"evf-field evf-field-date-time form-row\" data-field-id=\"qBRKKOtBAp-17\"><label class=\"evf-field-label\" for=\"evf-117-field_qBRKKOtBAp-17\"><span class=\"evf-label\">Treatment End Date<\/span> <\/label><input type=\"text\" id=\"evf-117-field_qBRKKOtBAp-17\" class=\"flatpickr-field input-text\" name=\"everest_forms[form_fields][qBRKKOtBAp-17]\" data-time-interval=\"15\" data-date-time=\"date\" data-mode=\"single\" data-locale=\"en\" data-date-format=\"Y-m-d\"  ><\/div><div id=\"evf-117-field_yNzNhyWj7r-19-container\" class=\"evf-field evf-field-date-time form-row\" data-field-id=\"yNzNhyWj7r-19\"><label class=\"evf-field-label\" for=\"evf-117-field_yNzNhyWj7r-19\"><span class=\"evf-label\">Expiry Date<\/span> <\/label><input type=\"text\" id=\"evf-117-field_yNzNhyWj7r-19\" class=\"flatpickr-field input-text\" name=\"everest_forms[form_fields][yNzNhyWj7r-19]\" data-time-interval=\"15\" data-date-time=\"date\" data-mode=\"single\" data-locale=\"en\" data-date-format=\"Y-m-d\"  ><\/div><\/div><\/div><div class=\"evf-frontend-row\" data-row=\"row_7\" conditional_rules=\"[]\"><div class=\"evf-frontend-grid evf-grid-1\" data-grid=\"grid_1\"><div id=\"evf-117-field_mSHayShb8K-20-container\" class=\"evf-field evf-field-file-upload form-row\" data-field-id=\"mSHayShb8K-20\"><label class=\"evf-field-label\" for=\"evf-117-field_mSHayShb8K-20\"><span class=\"evf-label\">Product Photo ( Batch Side )<\/span> <\/label>\t\t<div class=\"everest-forms-uploader\"\n\t\t\tdata-field-id=\"mSHayShb8K-20\"\n\t\t\tdata-form-id=\"117\"\n\t\t\tdata-input-name=\"everest_forms_117_mSHayShb8K-20\"\n\t\t\tdata-extensions=\"jpg,jpeg,jpe,gif,png,bmp,tiff,tif,webp,avif,ico,heic,heif,heics,heifs,asf,asx,wmv,wmx,wm,avi,divx,mov,qt,mpeg,mpg,mpe,mp4,m4v,ogv,webm,mkv,3gp,3gpp,3g2,3gp2,txt,asc,c,cc,h,srt,csv,tsv,ics,rtx,css,html,vtt,dfxp,mp3,m4a,m4b,aac,ra,ram,wav,x-wav,ogg,oga,flac,mid,midi,wma,wax,mka,rtf,pdf,class,tar,zip,gz,gzip,rar,7z,psd,xcf,doc,pot,pps,ppt,wri,xla,xls,xlt,xlw,mpp,docx,docm,dotx,dotm,xlsx,xlsm,xlsb,xltx,xltm,xlam,pptx,pptm,ppsx,ppsm,potx,potm,ppam,sldx,sldm,onetoc,onetoc2,onetmp,onepkg,oxps,xps,odt,odp,ods,odg,odc,odb,odf,wp,wpd,key,numbers,pages\"\n\t\t\tdata-max-size=\"268435456\"\n\t\t\tdata-max-file-number=\"1\"\n\t\t\tdata-post-max-size=\"268435456\"\n\t\t\tdata-current-file-count=\"0\"\n\t\t\t>\n\t\t\t<div class=\"dz-message\">\n\t\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 32 32\" width=\"32px\" height=\"32px\" fill=\"#868e96\"><path class=\"cls-1\" d=\"M18.12,17.52,17,16.4V25a1,1,0,0,1-2,0V16.4l-1.12,1.12a1,1,0,0,1-1.42,0,1,1,0,0,1,0-1.41l2.83-2.83a1,1,0,0,1,1.42,0l2.83,2.83a1,1,0,0,1-.71,1.7A1,1,0,0,1,18.12,17.52ZM22,22H20a1,1,0,0,1,0-2h2a4,4,0,0,0,.27-8,1,1,0,0,1-.84-.57,6,6,0,0,0-11.36,1.69,1,1,0,0,1-1,.86H9A3,3,0,0,0,9,20h3a1,1,0,0,1,0,2H9a5,5,0,0,1-.75-9.94A8,8,0,0,1,23,10.1,6,6,0,0,1,22,22Z\"\/><\/svg>\n\t\t\t\t<span class=\"everest-forms-upload-title\">\n\t\t\t\t\tDrop your file here or click here to upload\t\t\t\t<\/span>\n\n\t\t\t\t\t\t\t\t\t<span class=\"everest-forms-upload-hint\">\n\t\t\t\t\t\tYou can upload up to 1 files.\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<input type=\"text\" class=\"dropzone-input input-text\" id=\"everest-forms-117-field_mSHayShb8K-20\" name=\"everest_forms_117_mSHayShb8K-20\"  conditional_id=\"\" conditional_rules=''>\n\t\t<\/div><div id=\"evf-117-field_ALjVnmLU1r-21-container\" class=\"evf-field evf-field-textarea form-row\" data-field-id=\"ALjVnmLU1r-21\"><label class=\"evf-field-label\" for=\"evf-117-field_ALjVnmLU1r-21\"><span class=\"evf-label\">Relevant Medical History (If Available)<\/span> <\/label><textarea id=\"evf-117-field_ALjVnmLU1r-21\" class=\"input-text\" name=\"everest_forms[form_fields][ALjVnmLU1r-21]\"  ><\/textarea><\/div><div id=\"evf-117-field_3gT7t34alG-22-container\" class=\"evf-field evf-field-html form-row\" data-field-id=\"3gT7t34alG-22\"><div id=\"evf-117-field_3gT7t34alG-22\" class=\"input-text\"><div style=\"background:#8f2829;color:#fff;padding:12px 20px;border-radius:8px;font-size:18px;font-weight:700;margin:20px 0\">\r\nReporter Information\r\n<\/div><\/div><\/div><\/div><\/div><div class=\"evf-frontend-row\" data-row=\"row_8\" conditional_rules=\"[]\"><div class=\"evf-frontend-grid evf-grid-2\" data-grid=\"grid_1\"><div id=\"evf-117-field_FqZW4uGSjQ-24-container\" class=\"evf-field evf-field-first-name form-row\" data-field-id=\"FqZW4uGSjQ-24\"><label class=\"evf-field-label\" for=\"evf-117-field_FqZW4uGSjQ-24\"><span class=\"evf-label\">First Name<\/span> <\/label><input type=\"text\" id=\"evf-117-field_FqZW4uGSjQ-24\" class=\"input-text\" name=\"everest_forms[form_fields][FqZW4uGSjQ-24]\" placeholder=\"First Name\" ><\/div><\/div><div class=\"evf-frontend-grid evf-grid-2\" data-grid=\"grid_2\"><div id=\"evf-117-field_EFOZWvmPEu-23-container\" class=\"evf-field evf-field-last-name form-row\" data-field-id=\"EFOZWvmPEu-23\"><label class=\"evf-field-label\" for=\"evf-117-field_EFOZWvmPEu-23\"><span class=\"evf-label\">Last Name<\/span> <\/label><input type=\"text\" id=\"evf-117-field_EFOZWvmPEu-23\" class=\"input-text\" name=\"everest_forms[form_fields][EFOZWvmPEu-23]\" placeholder=\"Last Name\" ><\/div><\/div><\/div><div class=\"evf-frontend-row\" data-row=\"row_9\" conditional_rules=\"[]\"><div class=\"evf-frontend-grid evf-grid-1\" data-grid=\"grid_1\"><div id=\"evf-117-field_dbN6tSLfXR-25-container\" class=\"evf-field evf-field-address form-row\" data-field-id=\"dbN6tSLfXR-25\"><label class=\"evf-field-label\" for=\"evf-117-field_dbN6tSLfXR-25\"><span class=\"evf-label\">Address<\/span> <\/label><input id=\"dbN6tSLfXR-25\" type=\"hidden\" class=\"input-text evf-conditional-logic-holder\" conditional_rules=\"\" conditional_id=\"\" \/><\/div><\/div><\/div><div class=\"evf-frontend-row\" data-row=\"row_10\" conditional_rules=\"[]\"><div class=\"evf-frontend-grid evf-grid-2\" data-grid=\"grid_1\"><div id=\"evf-117-field_zfFVnAEryQ-26-container\" class=\"evf-field evf-field-text form-row\" data-field-id=\"zfFVnAEryQ-26\"><label class=\"evf-field-label\" for=\"evf-117-field_zfFVnAEryQ-26\"><span class=\"evf-label\">Address Line 1<\/span> <\/label><input type=\"text\" id=\"evf-117-field_zfFVnAEryQ-26\" class=\"input-text\" name=\"everest_forms[form_fields][zfFVnAEryQ-26]\" ><\/div><div id=\"evf-117-field_wKOybSyhoP-28-container\" class=\"evf-field evf-field-text form-row\" data-field-id=\"wKOybSyhoP-28\"><label class=\"evf-field-label\" for=\"evf-117-field_wKOybSyhoP-28\"><span class=\"evf-label\">City<\/span> <\/label><input type=\"text\" id=\"evf-117-field_wKOybSyhoP-28\" class=\"input-text\" name=\"everest_forms[form_fields][wKOybSyhoP-28]\" ><\/div><div id=\"evf-117-field_5uLmchfXWy-30-container\" class=\"evf-field evf-field-text form-row\" data-field-id=\"5uLmchfXWy-30\"><label class=\"evf-field-label\" for=\"evf-117-field_5uLmchfXWy-30\"><span class=\"evf-label\">Zip Code<\/span> <\/label><input type=\"text\" id=\"evf-117-field_5uLmchfXWy-30\" class=\"input-text\" name=\"everest_forms[form_fields][5uLmchfXWy-30]\" ><\/div><div id=\"evf-117-field_nEFpR5jiFe-32-container\" class=\"evf-field evf-field-number form-row\" data-field-id=\"nEFpR5jiFe-32\"><label class=\"evf-field-label\" for=\"evf-117-field_nEFpR5jiFe-32\"><span class=\"evf-label\">Phone\/Mobile<\/span> <\/label><input type=\"number\" id=\"evf-117-field_nEFpR5jiFe-32\" class=\"input-text\" name=\"everest_forms[form_fields][nEFpR5jiFe-32]\" placeholder=\"Mobile Phone\" \/><\/div><div id=\"evf-117-field_FvBTZZ8tVg-34-container\" class=\"evf-field evf-field-text form-row\" data-field-id=\"FvBTZZ8tVg-34\"><label class=\"evf-field-label\" for=\"evf-117-field_FvBTZZ8tVg-34\"><span class=\"evf-label\">Relationship with Patient<\/span> <\/label><input type=\"text\" id=\"evf-117-field_FvBTZZ8tVg-34\" class=\"input-text\" name=\"everest_forms[form_fields][FvBTZZ8tVg-34]\" ><\/div><\/div><div class=\"evf-frontend-grid evf-grid-2\" data-grid=\"grid_2\"><div id=\"evf-117-field_qW1DrsuTkI-27-container\" class=\"evf-field evf-field-text form-row\" data-field-id=\"qW1DrsuTkI-27\"><label class=\"evf-field-label\" for=\"evf-117-field_qW1DrsuTkI-27\"><span class=\"evf-label\">Address Line 2<\/span> <\/label><input type=\"text\" id=\"evf-117-field_qW1DrsuTkI-27\" class=\"input-text\" name=\"everest_forms[form_fields][qW1DrsuTkI-27]\" ><\/div><div id=\"evf-117-field_x53JYNdiBl-29-container\" class=\"evf-field evf-field-text form-row\" data-field-id=\"x53JYNdiBl-29\"><label class=\"evf-field-label\" for=\"evf-117-field_x53JYNdiBl-29\"><span class=\"evf-label\">State<\/span> <\/label><input type=\"text\" id=\"evf-117-field_x53JYNdiBl-29\" class=\"input-text\" name=\"everest_forms[form_fields][x53JYNdiBl-29]\" ><\/div><div id=\"evf-117-field_F6YsaDfFtw-31-container\" class=\"evf-field evf-field-country form-row\" data-field-id=\"F6YsaDfFtw-31\"><label class=\"evf-field-label\" for=\"evf-117-field_F6YsaDfFtw-31\"><span class=\"evf-label\">Country<\/span> <\/label><select id=\"evf-117-field_F6YsaDfFtw-31\" class=\"input-text\" name=\"everest_forms[form_fields][F6YsaDfFtw-31]\"  ><option value=\"\" class=\"placeholder\" disabled selected>--- Select a country ---<\/option><option value=\"AF\" >Afghanistan<\/option><option value=\"AX\" >\u00c5land Islands<\/option><option value=\"AL\" >Albania<\/option><option value=\"DZ\" >Algeria<\/option><option value=\"AS\" >American Samoa<\/option><option value=\"AD\" >Andorra<\/option><option value=\"AO\" >Angola<\/option><option value=\"AI\" >Anguilla<\/option><option value=\"AQ\" >Antarctica<\/option><option value=\"AG\" >Antigua and Barbuda<\/option><option value=\"AR\" >Argentina<\/option><option value=\"AM\" >Armenia<\/option><option value=\"AW\" >Aruba<\/option><option value=\"AU\" >Australia<\/option><option value=\"AT\" >Austria<\/option><option value=\"AZ\" >Azerbaijan<\/option><option value=\"BS\" >Bahamas<\/option><option value=\"BH\" >Bahrain<\/option><option value=\"BD\" >Bangladesh<\/option><option value=\"BB\" >Barbados<\/option><option value=\"BY\" >Belarus<\/option><option value=\"BE\" >Belgium<\/option><option value=\"PW\" >Belau<\/option><option value=\"BZ\" >Belize<\/option><option value=\"BJ\" >Benin<\/option><option value=\"BM\" >Bermuda<\/option><option value=\"BT\" >Bhutan<\/option><option value=\"BO\" >Bolivia<\/option><option value=\"BQ\" >Bonaire, Saint Eustatius and Saba<\/option><option value=\"BA\" >Bosnia and Herzegovina<\/option><option value=\"BW\" >Botswana<\/option><option value=\"BV\" >Bouvet Island<\/option><option value=\"BR\" >Brazil<\/option><option value=\"IO\" >British Indian Ocean Territory<\/option><option value=\"BN\" >Brunei<\/option><option value=\"BG\" >Bulgaria<\/option><option value=\"BF\" >Burkina Faso<\/option><option value=\"BI\" >Burundi<\/option><option value=\"KH\" >Cambodia<\/option><option value=\"CM\" >Cameroon<\/option><option value=\"CA\" >Canada<\/option><option value=\"CV\" >Cape Verde<\/option><option value=\"KY\" >Cayman Islands<\/option><option value=\"CF\" >Central African Republic<\/option><option value=\"TD\" >Chad<\/option><option value=\"CL\" >Chile<\/option><option value=\"CN\" >China<\/option><option value=\"CX\" >Christmas Island<\/option><option value=\"CC\" >Cocos (Keeling) Islands<\/option><option value=\"CO\" >Colombia<\/option><option value=\"KM\" >Comoros<\/option><option value=\"CG\" >Congo (Brazzaville)<\/option><option value=\"CD\" >Congo (Kinshasa)<\/option><option value=\"CK\" >Cook Islands<\/option><option value=\"CR\" >Costa Rica<\/option><option value=\"HR\" >Croatia<\/option><option value=\"CU\" >Cuba<\/option><option value=\"CW\" >Cura&ccedil;ao<\/option><option value=\"CY\" >Cyprus<\/option><option value=\"CZ\" >Czech Republic<\/option><option value=\"DK\" >Denmark<\/option><option value=\"DJ\" >Djibouti<\/option><option value=\"DM\" >Dominica<\/option><option value=\"DO\" >Dominican Republic<\/option><option value=\"EC\" >Ecuador<\/option><option value=\"EG\" >Egypt<\/option><option value=\"SV\" >El Salvador<\/option><option value=\"GQ\" >Equatorial Guinea<\/option><option value=\"ER\" >Eritrea<\/option><option value=\"EE\" >Estonia<\/option><option value=\"ET\" >Ethiopia<\/option><option value=\"FK\" >Falkland Islands<\/option><option value=\"FO\" >Faroe Islands<\/option><option value=\"FJ\" >Fiji<\/option><option value=\"FI\" >Finland<\/option><option value=\"FR\" >France<\/option><option value=\"GF\" >French Guiana<\/option><option value=\"PF\" >French Polynesia<\/option><option value=\"TF\" >French Southern Territories<\/option><option value=\"GA\" >Gabon<\/option><option value=\"GM\" >Gambia<\/option><option value=\"GE\" >Georgia<\/option><option value=\"DE\" >Germany<\/option><option value=\"GH\" >Ghana<\/option><option value=\"GI\" >Gibraltar<\/option><option value=\"GR\" >Greece<\/option><option value=\"GL\" >Greenland<\/option><option value=\"GD\" >Grenada<\/option><option value=\"GP\" >Guadeloupe<\/option><option value=\"GU\" >Guam<\/option><option value=\"GT\" >Guatemala<\/option><option value=\"GG\" >Guernsey<\/option><option value=\"GN\" >Guinea<\/option><option value=\"GW\" >Guinea-Bissau<\/option><option value=\"GY\" >Guyana<\/option><option value=\"HT\" >Haiti<\/option><option value=\"HM\" >Heard Island and McDonald Islands<\/option><option value=\"HN\" >Honduras<\/option><option value=\"HK\" >Hong Kong<\/option><option value=\"HU\" >Hungary<\/option><option value=\"IS\" >Iceland<\/option><option value=\"IN\" >India<\/option><option value=\"ID\" >Indonesia<\/option><option value=\"IR\" >Iran<\/option><option value=\"IQ\" >Iraq<\/option><option value=\"IE\" >Ireland<\/option><option value=\"IM\" >Isle of Man<\/option><option value=\"IL\" >Israel<\/option><option value=\"IT\" >Italy<\/option><option value=\"CI\" >Ivory Coast<\/option><option value=\"JM\" >Jamaica<\/option><option value=\"JP\" >Japan<\/option><option value=\"JE\" >Jersey<\/option><option value=\"JO\" >Jordan<\/option><option value=\"KZ\" >Kazakhstan<\/option><option value=\"KE\" >Kenya<\/option><option value=\"KI\" >Kiribati<\/option><option value=\"KW\" >Kuwait<\/option><option value=\"XK\" >Kosovo<\/option><option value=\"KG\" >Kyrgyzstan<\/option><option value=\"LA\" >Laos<\/option><option value=\"LV\" >Latvia<\/option><option value=\"LB\" >Lebanon<\/option><option value=\"LS\" >Lesotho<\/option><option value=\"LR\" >Liberia<\/option><option value=\"LY\" >Libya<\/option><option value=\"LI\" >Liechtenstein<\/option><option value=\"LT\" >Lithuania<\/option><option value=\"LU\" >Luxembourg<\/option><option value=\"MO\" >Macao<\/option><option value=\"MK\" >North Macedonia<\/option><option value=\"MG\" >Madagascar<\/option><option value=\"MW\" >Malawi<\/option><option value=\"MY\" >Malaysia<\/option><option value=\"MV\" >Maldives<\/option><option value=\"ML\" >Mali<\/option><option value=\"MT\" >Malta<\/option><option value=\"MH\" >Marshall Islands<\/option><option value=\"MQ\" >Martinique<\/option><option value=\"MR\" >Mauritania<\/option><option value=\"MU\" >Mauritius<\/option><option value=\"YT\" >Mayotte<\/option><option value=\"MX\" >Mexico<\/option><option value=\"FM\" >Micronesia<\/option><option value=\"MD\" >Moldova<\/option><option value=\"MC\" >Monaco<\/option><option value=\"MN\" >Mongolia<\/option><option value=\"ME\" >Montenegro<\/option><option value=\"MS\" >Montserrat<\/option><option value=\"MA\" >Morocco<\/option><option value=\"MZ\" >Mozambique<\/option><option value=\"MM\" >Myanmar<\/option><option value=\"NA\" >Namibia<\/option><option value=\"NR\" >Nauru<\/option><option value=\"NP\" >Nepal<\/option><option value=\"NL\" >Netherlands<\/option><option value=\"NC\" >New Caledonia<\/option><option value=\"NZ\" >New Zealand<\/option><option value=\"NI\" >Nicaragua<\/option><option value=\"NE\" >Niger<\/option><option value=\"NG\" >Nigeria<\/option><option value=\"NU\" >Niue<\/option><option value=\"NF\" >Norfolk Island<\/option><option value=\"MP\" >Northern Mariana Islands<\/option><option value=\"KP\" >North Korea<\/option><option value=\"NO\" >Norway<\/option><option value=\"OM\" >Oman<\/option><option value=\"PK\" >Pakistan<\/option><option value=\"PS\" >Palestinian Territory<\/option><option value=\"PA\" >Panama<\/option><option value=\"PG\" >Papua New Guinea<\/option><option value=\"PY\" >Paraguay<\/option><option value=\"PE\" >Peru<\/option><option value=\"PH\" >Philippines<\/option><option value=\"PN\" >Pitcairn<\/option><option value=\"PL\" >Poland<\/option><option value=\"PT\" >Portugal<\/option><option value=\"PR\" >Puerto Rico<\/option><option value=\"QA\" >Qatar<\/option><option value=\"RE\" >Reunion<\/option><option value=\"RO\" >Romania<\/option><option value=\"RU\" >Russia<\/option><option value=\"RW\" >Rwanda<\/option><option value=\"BL\" >Saint Barth&eacute;lemy<\/option><option value=\"SH\" >Saint Helena<\/option><option value=\"KN\" >Saint Kitts and Nevis<\/option><option value=\"LC\" >Saint Lucia<\/option><option value=\"MF\" >Saint Martin (French part)<\/option><option value=\"SX\" >Saint Martin (Dutch part)<\/option><option value=\"PM\" >Saint Pierre and Miquelon<\/option><option value=\"VC\" >Saint Vincent and the Grenadines<\/option><option value=\"SM\" >San Marino<\/option><option value=\"ST\" >S&atilde;o Tom&eacute; and Pr&iacute;ncipe<\/option><option value=\"SA\" >Saudi Arabia<\/option><option value=\"SN\" >Senegal<\/option><option value=\"RS\" >Serbia<\/option><option value=\"SC\" >Seychelles<\/option><option value=\"SL\" >Sierra Leone<\/option><option value=\"SG\" >Singapore<\/option><option value=\"SK\" >Slovakia<\/option><option value=\"SI\" >Slovenia<\/option><option value=\"SB\" >Solomon Islands<\/option><option value=\"SO\" >Somalia<\/option><option value=\"ZA\" >South Africa<\/option><option value=\"GS\" >South Georgia\/Sandwich Islands<\/option><option value=\"KR\" >South Korea<\/option><option value=\"SS\" >South Sudan<\/option><option value=\"ES\" >Spain<\/option><option value=\"LK\" >Sri Lanka<\/option><option value=\"SD\" >Sudan<\/option><option value=\"SR\" >Suriname<\/option><option value=\"SJ\" >Svalbard and Jan Mayen<\/option><option value=\"SZ\" >Swaziland<\/option><option value=\"SE\" >Sweden<\/option><option value=\"CH\" >Switzerland<\/option><option value=\"SY\" >Syria<\/option><option value=\"TW\" >Taiwan<\/option><option value=\"TJ\" >Tajikistan<\/option><option value=\"TZ\" >Tanzania<\/option><option value=\"TH\" >Thailand<\/option><option value=\"TL\" >Timor-Leste<\/option><option value=\"TG\" >Togo<\/option><option value=\"TK\" >Tokelau<\/option><option value=\"TO\" >Tonga<\/option><option value=\"TT\" >Trinidad and Tobago<\/option><option value=\"TN\" >Tunisia<\/option><option value=\"TR\" >Turkey<\/option><option value=\"TM\" >Turkmenistan<\/option><option value=\"TC\" >Turks and Caicos Islands<\/option><option value=\"TV\" >Tuvalu<\/option><option value=\"UG\" >Uganda<\/option><option value=\"UA\" >Ukraine<\/option><option value=\"AE\" >United Arab Emirates<\/option><option value=\"GB\" >United Kingdom (UK)<\/option><option value=\"US\" >United States (US)<\/option><option value=\"UM\" >United States (US) Minor Outlying Islands<\/option><option value=\"UY\" >Uruguay<\/option><option value=\"UZ\" >Uzbekistan<\/option><option value=\"VU\" >Vanuatu<\/option><option value=\"VA\" >Vatican<\/option><option value=\"VE\" >Venezuela<\/option><option value=\"VN\" >Vietnam<\/option><option value=\"VG\" >Virgin Islands (British)<\/option><option value=\"VI\" >Virgin Islands (US)<\/option><option value=\"WF\" >Wallis and Futuna<\/option><option value=\"EH\" >Western Sahara<\/option><option value=\"WS\" >Samoa<\/option><option value=\"YE\" >Yemen<\/option><option value=\"ZM\" >Zambia<\/option><option value=\"ZW\" >Zimbabwe<\/option><\/select><\/div><div id=\"evf-117-field_FzKDIshTIp-33-container\" class=\"evf-field evf-field-email form-row validate-required validate-email\" data-required-field-message=\"Please enter a valid email address.\" data-field-id=\"FzKDIshTIp-33\"><label class=\"evf-field-label\" for=\"evf-117-field_FzKDIshTIp-33\"><span class=\"evf-label\">Email<\/span> <abbr class=\"required\" title=\"Required\">*<\/abbr><\/label><input type=\"email\" id=\"evf-117-field_FzKDIshTIp-33\" class=\"input-text\" name=\"everest_forms[form_fields][FzKDIshTIp-33]\" placeholder=\"Email Address\" required ><\/div><div id=\"evf-117-field_SBEjtZsL9P-35-container\" class=\"evf-field evf-field-radio form-row\" data-field-id=\"SBEjtZsL9P-35\"><label class=\"evf-field-label\" for=\"evf-117-field_SBEjtZsL9P-35\"><span class=\"evf-label\">Are you also the patient<\/span> <\/label><ul id=\"evf-117-field_SBEjtZsL9P-35\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"evf-117-field_SBEjtZsL9P-35_1\" class=\"input-text\" name=\"everest_forms[form_fields][SBEjtZsL9P-35]\" value=\"YES\"  ><label class=\"everest-forms-field-label-inline\" for=\"evf-117-field_SBEjtZsL9P-35_1\">YES<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"evf-117-field_SBEjtZsL9P-35_2\" class=\"input-text\" name=\"everest_forms[form_fields][SBEjtZsL9P-35]\" value=\"NO\"  ><label class=\"everest-forms-field-label-inline\" for=\"evf-117-field_SBEjtZsL9P-35_2\">NO<\/label><\/li><\/ul><\/div><\/div><\/div><div class=\"evf-frontend-row\" data-row=\"row_11\" conditional_rules=\"[]\"><div class=\"evf-frontend-grid evf-grid-1\" data-grid=\"grid_1\"><div id=\"evf-117-field_ouoGONyjSq-36-container\" class=\"evf-field evf-field-privacy-policy form-row validate-required\" data-required-field-message=\"This field is required.\" data-field-id=\"ouoGONyjSq-36\"><label class=\"evf-field-label\" for=\"evf-117-field_ouoGONyjSq-36\"><span class=\"evf-label\">Privacy Policy<\/span> <abbr class=\"required\" title=\"Required\">*<\/abbr><\/label><input type=\"checkbox\" value=\"I confirm that the information provided is accurate and agree to the Privacy Policy. I consent to the use of my information for pharmacovigilance purposes.\" id=\"evf-117-field_ouoGONyjSq-36\" class=\"input-text\" name=\"everest_forms[form_fields][ouoGONyjSq-36]\" required \/><label class=\"evf-privacy-policy-consent-message\" for=\"evf-117-field_ouoGONyjSq-36\">I confirm that the information provided is accurate and agree to the Privacy Policy. I consent to the use of my information for pharmacovigilance purposes.<\/label><div class=\"evf-privacy-policy-local-page-contents\"><\/div><\/div><\/div><\/div><\/div><div class=\"evf-honeypot-container evf-field-hp\"><label for=\"evf-117-field-hp\" class=\"evf-field-label\">Name<\/label><input type=\"text\" name=\"everest_forms[hp]\" id=\"evf-117-field-hp\" class=\"input-text\"><\/div><div class=\"evf-submit-container \" ><input type=\"hidden\" name=\"everest_forms[id]\" value=\"117\"><input type=\"hidden\" name=\"everest_forms[author]\" value=\"1\"><button type='submit' name='everest_forms[submit]' class='everest-forms-submit-button button evf-submit ' id='evf-submit-117' value='evf-submit' data-process-text=\"Processing\u2026\" conditional_rules='&quot;&quot;' conditional_id='evf-submit-117'  id=\"evf-submit-117\" aria-live=\"assertive\">Submit<\/button><\/div><\/form><\/div><!-- .evf-container --><\/div> <\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-d7ed5df e-con-full e-flex wpr-particle-no wpr-jarallax-no wpr-parallax-no wpr-sticky-section-no wpr-column-slider-no wpr-equal-height-no e-con e-parent\" data-id=\"d7ed5df\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-bc48f21 elementor-widget elementor-widget-heading\" data-id=\"bc48f21\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">If you prefer to submit your report by mail, please download the reporting form and send the completed form to the address below.<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-edd07f1 elementor-widget elementor-widget-text-editor\" data-id=\"edd07f1\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t\t\t\t\t\t<strong>Innovative Lifesciences Pvt. Ltd.<\/strong><br><br>\n\n<strong>Registered Office:<\/strong>\nSCO-4, 2nd Floor, Swastik Vihar, Mansa Devi Complex, Sector 5, Panchkula, Haryana \u2013 134109<br>\n\n<strong>Phone:<\/strong>\n<a class=\"contact-link\" href=\"tel:+9185588 11543\">+91 85588 11543<\/a><br>\n\n<strong>Email:<\/strong>\n<a class=\"contact-link\" href=\"mailto:innovativegroupcompanies@gmail.com\">innovativegroupcompanies@gmail.com<\/a>\n\n<style>\n.contact-link{<br \/>    color:#626262;<br \/>    text-decoration:none;<br \/>    transition:.3s;<br \/>}<\/p>\n<p>.contact-link:hover{<br \/>    color:#e61563 !important;<br \/>}<br \/><\/style>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-3daf557 elementor-widget elementor-widget-heading\" data-id=\"3daf557\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Adverse Event Reporting<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-ba50d13 elementor-widget elementor-widget-text-editor\" data-id=\"ba50d13\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t\t\t\t\t\t<p class=\"PDq2pG_selectionAnchorContainer\" data-start=\"535\" data-end=\"729\">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.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-47471d4 elementor-widget elementor-widget-heading\" data-id=\"47471d4\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Who Can Report?<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-6647746 elementor-widget elementor-widget-text-editor\" data-id=\"6647746\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t\t\t\t\t\t<ul><li class=\"v9V1QG_Item\" data-w-component=\"list-item\"><div class=\"ac5DTa_Box v9V1QG_Content\" data-w-direction=\"col\" data-w-auto-spacing=\"\" data-w-list-content=\"\"><p class=\"zlAe0W_TextBase zlAe0W_Text\" data-w-component=\"text\" data-w-wrap=\"normal\">Healthcare Professionals (Doctors, Dentists, Nurses, Pharmacists, etc.)<\/p><\/div><\/li><li class=\"v9V1QG_Item\" data-w-component=\"list-item\"><div class=\"ac5DTa_Box v9V1QG_Content\" data-w-direction=\"col\" data-w-auto-spacing=\"\" data-w-list-content=\"\"><p class=\"zlAe0W_TextBase zlAe0W_Text\" data-w-component=\"text\" data-w-wrap=\"normal\">Patients, Caregivers, Relatives, or Consumers<\/p><\/div><\/li><\/ul>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-b2e0f66 elementor-widget elementor-widget-heading\" data-id=\"b2e0f66\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Confidentiality<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-9944d16 elementor-widget elementor-widget-text-editor\" data-id=\"9944d16\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t\t\t\t\t\t<p>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.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>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) 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 \u2013 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.<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_header_footer","meta":{"footnotes":""},"class_list":["post-108","page","type-page","status-publish","hentry"],"_hostinger_reach_plugin_has_subscription_block":false,"_hostinger_reach_plugin_is_elementor":false,"_links":{"self":[{"href":"https:\/\/innovativelifesciences.in\/adr\/wp-json\/wp\/v2\/pages\/108","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/innovativelifesciences.in\/adr\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/innovativelifesciences.in\/adr\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/innovativelifesciences.in\/adr\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/innovativelifesciences.in\/adr\/wp-json\/wp\/v2\/comments?post=108"}],"version-history":[{"count":52,"href":"https:\/\/innovativelifesciences.in\/adr\/wp-json\/wp\/v2\/pages\/108\/revisions"}],"predecessor-version":[{"id":185,"href":"https:\/\/innovativelifesciences.in\/adr\/wp-json\/wp\/v2\/pages\/108\/revisions\/185"}],"wp:attachment":[{"href":"https:\/\/innovativelifesciences.in\/adr\/wp-json\/wp\/v2\/media?parent=108"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}