Nikan Pharmed

Ministry of Health, Treatment, and Medical Education
Food and Drug Administration

Center for the Registration and Evaluation of Adverse Drug Reactions (ADR)

National Identification Number :

Full Name :

Date of Birth :

Age :

Weight :

Gender : Male Female Pregnant

Residence Address :

Telephone Number :

Type/s of Adverse Drug Reactions Observed and the Treatments Performed :

Adverse Reactions Start Date :

How long the adverse reaction lasted for ?

Previous history of adverse drug reactions ?

Disease history (Allergies, Heridatory ,Autoimmune, Current Conditions, etc ....)

Did the adverse reaction stop after Discontinuing medication ? Yes No Medication is being continued

Did the adverse reactions reappear after continuing medication ? Yes No Medication was not used again

Result of adverse reactions : Treated Not Treated Morbidity Death Others

Did the adverse reactions lead to hospitalization ? Yes No

Results of adverse reactions-related para-clinical tests of the drug :

Suspected Drug/s Causing Adverse Reactions :

Drug	Dose and Dosage	Daily Intake	Route of Administration	Indications	Start Date	End Date	Manufacturer and Batch Number

Suspected Drug/s Causing Adverse Reactions : =

Drug	Dose and Dosage	Daily Intake	Route of Administration	Indications	Start Date	End Date	Manufacturer and Batch Number

Remarks :

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Adverse Drug Reactions

Have you used any of our products and experienced adverse reactions?
If the answer is yes, then please contact us using one of the options below.
We will make sure our pharmacovigilance experts reach out to you
and provide necessary assistance about any issues pertaining
to the use of our products.
You may also fill in the ADR Report form
so that we can assist you better with your problem :

Contact Info:
Handphone: +98-9052306669
WhatsApp: +98-9052306669
Email: pv@nikanpharmed.com

Fill in the ADR Report Form

Ministry of Health, Treatment, and Medical Education Food and Drug Administration

Center for the Registration and Evaluation of Adverse Drug Reactions (ADR)

Adverse Drug Reactions

Ministry of Health, Treatment, and Medical Education
Food and Drug Administration