Adverse Drug Reaction (ADR) Reporting Form

Important Notice: This form is intended solely for reporting Adverse Drug Reactions (ADRs), side effects, and safety information related to products manufactured by Unijules Life Sciences Limited.

This form must not be used for: Medical advice requests, Product information requests, Commercial inquiries, Job applications, Complaints unrelated to patient safety, Reports concerning products manufactured by other companies. Reports not related to Company products will not be processed through this portal.

Section 1: Eligibility Check

Is the suspected product manufactured by Unijules Life Sciences Limited?

Yes No

Section 2: Reporter Information

Reporter Type

Patient Healthcare Professional Pharmacist Caregiver Other

Reporter Name Email Address Phone Number Country

Section 3: Patient Information

Patient Initials Age (Years) Gender

Male Female Other Prefer not to say

Weight (kg) (Optional)

Section 4: Suspected Product Information

Product Name Strength Dosage Form

Tablet Capsule Injection Syrup Cream/Ointment Other

Batch/Lot Number (if available) Indication (Reason for Use) Therapy Start Date Therapy Stop Date (if applicable)

Section 5: Adverse Reaction Details

Description of Adverse Reaction/Event

(Mandatory narrative field)

Date Reaction Started Date Reaction Ended (if applicable) Outcome

Recovered Recovering Not Recovered Recovered with Sequelae Fatal Unknown

Section 6: Seriousness Assessment

Was the reaction serious?

Yes No

Section 7: Concomitant Medications (Optional)

Please list any other medicines taken at the time of the reaction.

Section 8: Relevant Medical History (Optional)

Please provide any relevant medical conditions, allergies, or previous adverse reactions.

Section 9: Supporting Documents (Optional)

Upload supporting documents such as:

Medical reports
Laboratory reports
Hospital discharge summaries
Prescriptions

Accepted formats: PDF, JPG, PNG, DOC, DOCX. Max 5MB per file (files are emailed, not stored on the server).

Section 10: Consent and Declaration

I confirm that the information provided is accurate to the best of my knowledge. I understand that this information will be processed for pharmacovigilance and drug safety monitoring purposes. I have read and understood the Privacy Notice.