Contact

Johannesburg Office

Tel: +27 11 312 3812
Fax: +27 11 312 7814

Physical address:
Unit 7, Royal Palm Business Estate,
646 Washington Street,
Halfway House, Midrand,
1685

Postal address:
PO Box 7408,
Halfway House,
1685

Durban Office

Tel: +27 31 265 0265
Fax: +27 31 265 0224

Physical address:
Westway Office Park,
Ground floor, 13 The Boulevard,
Westville,
3635

General Enquiry

    Adverse Events

      Source

      Consequence

      Reporter Details

      Patient Information

      Do you provide consent for further follow-up by our pharmacovigilance department regarding adverse event information that may be required?

      Product Details

      Did event/s reappear after medication was reintroduced?

      Did event/s diminish after medication was stopped or reduced?

      Start Date of Use

      Stop Date (If Applicable)

      Expiry Date

      Manufactured Date

      Action Taken

      Adverse Event Details

      Adverse Event Start Date

      Adverse Event/s Stop Date (If Applicable)

      Outcome of Event

      Was Treatment Received

      Concomitant Medication

      Only answer below questions if Yes
      YesNo

      Date Started

      Stop Date (If Applicable)

      Other Relevant Information, if Applicable:

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