Nexipox Advance PFS is Top Chickenpox Varicella Vaccine India

Reporter Details/ (रिपोर्टर विवरण)

Full Name/ (पूरा नाम) *

Occupation/ (व्यवसाय)

Email Address/ (ईमेल पता) *

Telephone Number/ (टेलीफोन नंबर) *

Appartment/House/Plot Number

Street Name

Landmark

Pin Code*

City*

State/ (राज्य)*

Country/ (देश) *

If reporter is the patient/ (अगर रिपोर्टर मरीज है):

Yes

Patient Details/ (रोगी विवरण)

Name/ (नाम) *

Date of Birth/ (जन्म की तारीख) *

Gender/ (लिंग) *

Email Address/ (ईमेल पता) *

Telephone Number/ (टेलीफोन नंबर) *

Suspect Drug Details/ (संदिग्ध दवा विवरण)

Name of drug/ (औषधि का नाम) *

Batch no./ (बैच नम्बर) *

Expiry date/ (समाप्ति तिथि) *

Dose/ (खुराक)

Frequency/ (आवृत्ति)

Start date/ (आरंभ करने की तिथि)

Stop date/ (स्टॉप डेट)

Adverse Event Details/ (प्रतिकूल घटना विवरण)

Description of event/ (घटना का विवरण) *

Intensity/ (तीव्रता):

Severe/ (गंभीर)

Moderate/ (उदारवादी)

Mild/ (हल्का)

Note :

Fields marked “*” are mandatory and needs to be filled before submitting.
You may also send us Adverse Event Information by filling the below forms and sending the same to the address mentioned below
Vaccine Products

Address: 1301-1305, 13th Floor, Commercial Wing-A, The Epicentre, W.T.Patil Marg.Borla Village, near Shivaji Chowk, Chembur East-400071.
Email: drugsafety@novomedi.com
Call us at Toll free no- 1800 309 0896

Inspired By Value, Driven By Vision

Report Adverse Event

Reporter Details/ (रिपोर्टर विवरण)

Patient Details/ (रोगी विवरण)

Suspect Drug Details/ (संदिग्ध दवा विवरण)

Adverse Event Details/ (प्रतिकूल घटना विवरण)

Note :