Impax Adverse Event and Product Complaint Report Form
Complete as many details as possible and submit the form.
Your Details
Date of Report
MM
/
DD
/
YYYY
Date Aware of Adverse Event and/or Product Complaint
MM
/
DD
/
YYYY
Your Name
Your answer
Your Contact Telephone Number or Email
Your answer
Impax Drug Details
Drug Name(s)
Your answer
Adverse Event or Product Complaint Details
Your answer
Patient Details
Patient Initials
Your answer
Date of Birth, Age or Age Category
Your answer
Sex
Reporter Details
Person who provided you with details, if different from patient
Reporter Name
Your answer
Reporter Telephone No
Your answer
Reporter Email
Your answer
Reporter Address
Your answer
Reporter Type
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