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For product complaints or reporting on adverse events, please call us on below number or send the details at below email id.
QUERY FORM For product complaints or reporting on adverse events, please send the details at below email id. qualityhead@thetapharma.com qa@thetapharma.com +91 63950 03459
All asterisk (*) fields are mandatory to fill
Your Name*
Date of Birth
Gender--Please choose an option--MaleFemaleOther
Contact No.
Email Id
Reporting for/by*
SelfPhysician/PrescriberOther
Event/Reaction Term (Eg: Headache)*
Event/Reaction Start Date*
Event/Reaction Stop Date*
Onset Duration Time*
Seriousness of the reaction*
NoYes
Seriousness Type—Please choose an option—--- Please choose an option ---DeathLife threateningInvolved or Prolonged inpatient HospitalizationCongenital-anomalyDisabilityOther Medical Inportant
Describe Reaction details
Outcomes*RecoveredRecoveringNot RecoveredFatalRecovered with SequalaeUnknown
Additional Supporting documents
S.No.
Name (Brand/Generic)*
Batch No.
Dose Used
Route
Freq.
Units
Expiry Date
Therapy Start
Therapy End
Indication (Used for)
1
2
Action Taken* —Please choose an option——Please choose an option—Drug withdrwanDose increasedDose reducedDose not ChangedNot applicableUnknown
Reaction abated after stopping drug?* —Please choose an option—--Please choose an option--YesNoUnknownNot applicable
Reaction reappeared after reintroduction?* —Please choose an option—--Please choose an option--YesNoUnknownNot applicable
Relationship of event with drug —Please choose an option—--Please choose an option--RelatedNot Related
Dose used*
Route used*
Daily Dose (s)*
Therapy Start Date*
Therapy End Date*
Indication*
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