Complaint
Sample ID
Location of suspected Medicine
*
Brand Name
Indication
Batch No
No of Dosage Received, Date & Conditions
Manufacturer
Type of Problem Occurred, Time, Circumstances
Country Of Origin
Sample Cty
Expiry Date
-
Day
-
Month
Year
Date
Name
*
Occupation
*
Address
District
*
Upazilla
*
Union
Post Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Attachment
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