How to Report Adverse Events

In order for us to monitor and assess the ongoing safety of our products, we encourage patients and healthcare professionals to report suspected adverse events”

“Adverse effects” or “Adverse events” refer to the unintended or undesirable events subsequent to use of a medicine.

If you believe you have experienced a side effect from one of our medicines, please take the following actions:

  • Contact your doctor, pharmacist or nurse who can then notify Pharmax
  • Pharmax can be contacted through the following channels

Filling and submitting the below online form

By Phone : +971 4 2486500/ +971 4 2486512

By email : medicines.info@pharmax.ae

Download as pdf

    Date of Event

    Event Date*

    Reporter Details

    Full Name*

    Email ID*

    Phone*

    Address

    Patient Information

    Full Name

    Email ID*

    Gender*

    MaleFemale

    Age/Date of Birth*

    Weight


    Telephone*

    Address

    Adverse Drug Reaction

    Description of Event*

    Start Date of Reaction*

    End Date of Reaction

    Is the ADR serious?*

    YesNo

    If YES REASON FOR SERIOUSNESS

    Suspected Medication

    Drug Name*

    Generic Name*

    Strength

    Batch No

    Mfg Date

    Expiry Date

    Daily Dose

    Indication

    Start Date*

    Stop Date

    Concomitant Medication (S)

    Drug Name

    Generic Name

    Daily Dose

    Indication

    Start Date

    Stop Date

    Action taken to Treat ADR

    Medical TreatmentDrug StoppedDrug Reduced

    Did the ADR subside after stopping the suspected medication

    YesNo

    Medical History

    Condition

    Onset

    Details

    Present

    YesNo

    Outcome of the Adverse Reaction

    RecoveredRecoveringNo improvementUnknown

    Pharmacy/Hospital Name

    Pharmacy

    Hospital

    Name of Healthcare Professional*

    Signature*

    Date*

    Additional Information

    *Indicates mandatory fields

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