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Drug Reaction Reporting Form

  • Patient Information
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  • Suspected Drug(s) Information
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  • Suspected Reaction(s) Information
  • MM slash DD slash YYYY
  • Seriousness
  • Concomitant Drug(s)
  • NameConcentrationRouteDose & FrequencyUsed forDate StartedDate StoppedBatch Number 
  • Reporter Details

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