Havix Group Inc., D/B/A Aavis Pharmaceuticals (A Subsidiary of Senores Pharmaceuticals Ltd.)

ADVERSE DRUG EXPERIENCE/PRODUCT QUALITY COMPLAINT FORM

Tell us about who are you?
I am a Healthcare Professional
I am a Patient or Relative
I am an AAVIS Pharmaceuticals Employee or Vendor
Select as Appropriate about Your Complaint
Adverse Drug Experience (s)
Product Quality Complaint (s)
Information About Yourself

Reporter Details

Name of Reporter

Contact Details

City

Postal Code

Country

If you are a patient and reporter, tick as appropriate

Yes No

Patient Details

Patient Name (In Confidence)

Age

Height

Weight

Gender

Ethnicity

Race

I, the patient/reporter, consent to AAVIS for contacting me via Email Phone Both

Describe about Suspected Product

Product Name

Indication for use

Lot No.

Expiry date

Dose

Frequency

Start Date

Stop Date

Ongoing

Describe the Adverse Drug Experience (s) or Product Quality Complaint(s)

Start Date

Stop Date

What is the outcome of the Adverse Drug Experience (s)?
Complete Recovery
Condition Deteriorated
Condition Improving
Condition Unchanged
Fatal or Death
Unknown

Did any of the following occur as a result of the adverse drug experience (s)?
Death
Hospitalization-Initial/ Prolonged
Immediate Life Threatening
Permanent or significant disability/incapacity
Congenital Anomaly

Provide the Medical History

Description

Disease/Disorder

Start Date

Stop Date

Ongoing