Query Form

For product complaints or reporting on adverse events, Please contact us on below email.

HETERO INDIA

Mail Us: ae.pvg@hetero.com

REPORTER INFORMATION

Name/Initials *

Age or Date of Birth *

Gender *

Contact No. *

Email ID

Reporting for/by *

Self

Physician/Prescriber

Others

Country of Incidence

SUSPECTED ADVERSE REACTION

Event Term (Eg: Headache, Vomiting, etc) *

Event Reaction Start Date

Event Reaction Stop Date

Onset Duration Time

Seriousness of the reaction

Yes

Serouisness Type

Describe Event/Reaction with treatment details, if any

Outcomes

Additional Supporting documents

ACTION TAKEN

Name (Brand/Generic)

Event Relatedness to drug

Did Reaction abate after stopping drug?

Did Reaction reappear after Reintroduction?

CONCOMITANT MEDICATION (S)

Name (Brand/Generic)

Dose used

Route used

Daily Dose (s)

Therapy Start Date

Therapy End Date

Indication

Relevant Medical History/Lab Tests

Additional Supporting documents

If you would like to send us information via e-mail, Please download the ADR form below and mail it to ae.pvg@hetero.com

Query Form

HETERO INDIA

REPORTER INFORMATION

SUSPECTED ADVERSE REACTION

Additional Supporting documents

ACTION TAKEN

Add Drugs

CONCOMITANT MEDICATION (S)

Add Drugs

Additional Supporting documents