Pharmacovigilance

CONTACT

التيقظ الدوائي.

In case of reporting an adverse event to medications, please fill out the following form below:

Patient First Initial's (3 Letters)

Gender

Approximate Weight (KG)

Age (Years Completed)

Name of Medicine and Prescription

Batch Number of Medicine

Expiration Date of Medicine

Dose Administrated

Date your started taking the medication

Date on which the medication was completed

Reason for taking the medicine

What has been the adverse reaction you have experienced?

Date of onset of adverse reaction

Date you stopped experiencing adverse reaction

Regarding the adverse reaction experienced, select the option that best describes the statement

Has it left any health consequences?

If yes please explain the health sequel:

About the event that followed the adverse reaction:

If yes please explain the health sequel:

Name of the person reporting the adverse event:

Contact Phone Number:

By selecting the “I accept” box, you consent to share your personal data with Akeel Health, as the adverse event notifier, solely for the purposes of reporting the corresponding adverse events. Such personal data includes your name, telephone number, and contact email. In addition, in order to comply with current pharmacovigilance regulations, you also consent to Akeel Health sharing such personal data with the Ministry of Health. Finally, we guarantee that, in accordance with our Personal Data Protection Policy, we will take all appropriate security measures to ensure that the confidentiality of your personal data is preserved and is not used for any other purpose.

Single choice

I accept.

I do not accept.