ADR Form (Patient/Care-giver)
The public is encouraged to provide the following preliminary information for all ADR reports sent directly to MedixCare
Email
*
example@example.com
Name
*
First Name
Last Name
What is your Gender
Male
Female
Prefer not to say
Birth Date
-
Day
-
Month
Year
Date
Phone Number
-
Area Code
Phone Number
Product responsible for the ADR(s)
*
Batch Number of product
*
Expiry Date of product
*
Manufacturer of product
*
Please describe the adverse event(s)
*
Submit
Should be Empty: