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 2486513

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

Date of Birth*

Weight*


Telephone*

Address

Adverse Drug Reaction

Description of Event

Start Date of Reaction*

End Date of Reaction*

Time of Reaction*

Is the ADR serious?*

YesNo

Suspected Medication

Drug Name*

Generic Name*

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 ADR

ResolvedLost to follow upUnknown

Pharmacy/Hospital Name

Pharmacy

Hospital

Name of Healthcare Professional*

Signature*

Date*

Additional Information

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Ministry of Health Health and Prevention Advertisement License No : IN0W3681-140720 valid till 15/07/2021