Skip to content
Home
About Us
Social Responsibilities
Departments
Logistics
Planning and Purchasing
Supply Chain
Sales & Marketing
Governmental Sales
Finance
Human Resources
IT
AMCORP Academy
Contact Us
Pharmacovigilance
Supply
Medical Supplies
Health Care & Cosmetics
Home
About Us
Social Responsibilities
Departments
Logistics
Planning and Purchasing
Supply Chain
Sales & Marketing
Governmental Sales
Finance
Human Resources
IT
AMCORP Academy
Contact Us
Pharmacovigilance
Supply
Medical Supplies
Health Care & Cosmetics
العربية
Search
Home
About Us
Social Responsibilities
Departments
Logistics
Planning and Purchasing
Supply Chain
Sales & Marketing
Governmental Sales
Finance
Human Resources
IT
AMCORP Academy
Contact Us
Pharmacovigilance
Supply
Medical Supplies
Health Care & Cosmetics
Home
About Us
Social Responsibilities
Departments
Logistics
Planning and Purchasing
Supply Chain
Sales & Marketing
Governmental Sales
Finance
Human Resources
IT
AMCORP Academy
Contact Us
Pharmacovigilance
Supply
Medical Supplies
Health Care & Cosmetics
العربية
Adverse Event-Quality Issue Report Form
Name
Date of Birth
Country
-Select Country-
Saudi Arabia
United Arab Emirates
Oman
Bahrain
Qatar
Kuwait
Iraq
Lebanon
Yemen
Jordan
Libya
Sri Lanka
Gender
Male
Female
Pregnancy Status:
Yes
No
Description of the adverse event (including relevant tests/lab data):
Image
Seriousness
Serious
Non-serious
If Serious
If Serious
Patient Death
Involved or prolonged hospitalization
Involved persistent or significant disability
Birth defect
Threat to life
Reaction Onset:
Event subsided after stopping:
Yes
No
N/A
Event reappear after reintroducing:
Yes
No
N/A
Drug Name
Drug A
Drug B
Daily Dose:
Route of Administration
Indication:
Duration of Therapy:
Action Taken:
Details of Concomitant Drug(s):
Relevant History:
Description of Quality Issue:
Image of Medication
Batch Number:
Expiry Date:
Name:
Specialty:
Your Signature
Institute:
Send
Name
Date of Birth
Country
-Select Country-
Saudi Arabia
United Arab Emirates
Oman
Bahrain
Qatar
Kuwait
Iraq
Lebanon
Yemen
Jordan
Libya
Sri Lanka
Gender
Male
Female
Pregnancy Status:
Yes
No
Description of the adverse event (including relevant tests/lab data):
Image
Seriousness
Serious
Non-serious
If Serious
If Serious
Patient Death
Involved or prolonged hospitalization
Involved persistent or significant disability
Birth defect
Threat to life
Reaction Onset:
Event subsided after stopping:
Yes
No
N/A
Event reappear after reintroducing:
Yes
No
N/A
Drug Name
Drug A
Drug B
Daily Dose:
Route of Administration
Indication:
Duration of Therapy:
Action Taken:
Details of Concomitant Drug(s):
Relevant History:
Description of Quality Issue:
Image of Medication
Batch Number:
Expiry Date:
Name:
Specialty:
Your Signature
Institute:
Send
