If you have observed / suffered some side effect of any medicine, please give detail in the following format.

As a responsible citizen, your information will help us to compile the data observed worldwide and will help the society to overcome the adverse reactions / side effects and their preventive measure for the benefit of the society at large.

FEEDBACK FORM
For voluntary reporting of suspected adverse drug reactions / side effects.
Please express your observations even if you are not sure or certain.
The data shall be used for research and statistical purposes only.
Give maximum possible information or leave blank if not known. (*Marked columns are mandatory.)