• SUSPECT ADVERSE REACTION REPORT

  • 1.REACTION INFORMATION

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY

  • 2. SUSPECT DRUG(S) INFORMATION

  • 3. CONCOMITANTS DRUGS AND HISTORY

  • 4. MANUFACTURER INFORMATION

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY