Query Form

For product complaints or reporting on adverse events, Please call us on below number/email below.

HETERO INDIA

Toll free number- 1800-120-8689 , Mail Us: drugsafetyINDIA@hetero.com.

REPORTER INFORMATION

Name/Initials (नाम/प्रथमाक्षर) *

Age or Date of Birth (आयु या जन्मतिथि) * *

Gender (लिंग) *

Contact No. (संपर्क सं) *

Email ID (ईमेल आईडी)

Reporting for/by (के लिए/द्वारा सूचना देने के लिए) *

Self Physician/Prescriber Others

Country of Incidence (घटना का देश)

SUSPECTED ADVERSE REACTION

Event Term (घटना का नाम)(Eg: Headache, Vomiting etc उदहारण: सिरदर्द, उल्टी आदि)*

Event Reaction Start Date (घटना प्रतिक्रिया प्रारंभ तिथि)

Event Reaction Stop Date (घटना प्रतिक्रिया बंद होने की तिथि)

Onset Duration Time (शुरुआत अवधि समय)

Seriousness of the reaction (प्रतिक्रिया की गंभीरता)

Yes

Describe Event/Reaction with treatment details, if any (उपचार विवरण के साथ घटना/प्रतिक्रिया का वर्णन करें, यदि कोई हो)

Outcomes (निष्कर्ष)

Additional Supporting documents

ACTION TAKEN

Name (Brand/Generic)

Event Relatedness to drug

Did Reaction abate after stopping drug? (क्या दवा बंद करने के बाद प्रतिक्रिया बंद हो गई?)

Did Reaction reappear after Reintroduction? (क्या पुनरारंभ के बाद प्रतिक्रिया फिर से प्रकट हुई?)

CONCOMITANT MEDICATION (S)

Name (Brand/Generic)

Dose used

Route used

Daily Dose (s)

Therapy Start Date

Therapy End Date

Relevant Medical History/Lab Tests (प्रासंगिक चिकित्सा इतिहास / प्रयोगशाला जाँच)

Additional Supporting documents

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

Download Adverse Event Reporting Form

ADR -Reporting Forms-Hetero Hindi

Query Form

HETERO INDIA

REPORTER INFORMATION

SUSPECTED ADVERSE REACTION

Additional Supporting documents

ACTION TAKEN

Add Drugs

CONCOMITANT MEDICATION (S)

Add Drugs

Additional Supporting documents