Our Products
Our Products

Adverse Event Form

    ADVERSE EVENT FORM





    Information about the patient who experienced the event:







    Details of the reaction (including relevant Tests/Lab Data:



    What happened to the patient?

    Patient Died YesNo
    Life-threatening YesNo
    Patient Hospitalized YesNo
    Significant Disability or Incapacity YesNo

    Which AGP drug involved:







    YesNoNA



    Concomitant Drugs & Date of Administration (Exclude those used to treat reactions):



    Who reported the Adverse Event?













    FORM MK - 03-02