Product Complaint Intimation / Adverse Event Reporting form
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*Name:
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*Contact Number:
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| Email:
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*Country:
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*Date of receipt of Complaint:
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*Product Name and Strength:
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*Description of Complaint:
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| Batch Number:
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| Manufacturing Month:
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Manufacturing year:
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| Expiry Month:
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Expiry Year:
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*Complainant:
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| Contact Details of Complainant: (Put 'NA' if information is not available)
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| Complaint Sample Available?
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| Remarks:
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Note: Please upload files up to 16MB.(File type can be DOC, DOCX, PDF, JPG, JPEG, PNG and Video.)(Max Video size is 8MB.)
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| Select Files
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| Enter Image Text Code Here :
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