Torrent Pharma Inc.
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Adverse Event or Product Problem Reporting Form

Patient Info  Adverse Event, Product Problem or Error Details  Suspected Product Information  Information On Reporter
 
A. Patient Information
1. Full Name    
2. Birthday:   Or Age:
3. Sex:
4. Weight: lbs
5. Country:  
6. State/Province:
7. Address 1: (*Required)  
8. Address 2:
9. Zip Code: (*Required)  
10. Phone:
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