Report of suspected quality issues
Please fill in the form below.
Date
/
Month
/
Day
Year
Date
Name of Drug:
Name of active ingredients
Dosage form
Batch No:
Name of Manufacturer:
Country of manufacture
Date of purchase
Expiry date
-
Month
-
Day
Year
Date
Name of supplier
Storage conditions
Please indicate which quality requirement is substandard (please click all that apply)
Discoloration
Yes
No
Unpalatable
Yes
No
Presence of particles/Lichen
Yes
No
Disintegration
Yes
No
Cracking
Yes
No
Defective packaging
Yes
No
Brief description of the above issue(s) : Optional
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Upload any photo or file if available
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of
Other quality issues
Name and professional address
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Report will be sent to the National Pharmacovigilance Committee
10th Floor, Emmanuel Anquetil Building Port Louis
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