CN

pharmacovigilance

Name:

Contact Information:*

Drug Name:*

Product Batch Number:

Reason for medication:

Dosage and Administration:

Medication Start and End Time:

Adverse Reaction Occurrence Time:

Adverse Reaction Symptoms:*

Brief Description of Adverse Reaction:

Reporter:

“ * ” are required fields

Scan with WeChat Adverse Reaction Reporting Mini Program

Service Hotline

0532-85563809