Product Complaint Intimation / Adverse Event Reporting form

*Name: *Contact Number:
Email: *Country:
*Date of receipt of Complaint: *Product Name and Stregth:
*Description Of Complaint:
Batch Number:
Manufacturing Month: Manufacturing year:
Expiry Month: Expiry Year:
*Complainant:-
Contact Details of Complainant:- (Put 'NA' if information is not available)
Complaint Sample Available?
Remarks:
 
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