Report Adverse Events

Your Location *
Language *
Which best describes you?
I am a…. *
What would you like to report?

Legal Disclaimer
We are legally obligated to collect and, when necessary, report adverse event data to health authorities. To comply with these requirements, any personal information that could identify you will be pseudonymized in our adverse event database.

If you have experienced an adverse event or suspect you might be, please consult a healthcare professional.

Vendor Information

Salutation
First Name
Last Name *
Organisation Name *
Email *
Who is the reporter? *

Reporter Information

Salutation
First Name
Last Name *
Email Address *
Phone
Address
Country
Date Of Birth
Gender at birth *
Height (Cm)
Weight (Kg)
Please provide any relevant medical history.

Healthcare Provider

Can we follow up with your healthcare provider if we have additional questions or need to respond to your request?

Healthcare Provider's Detail

Salutation
First Name
Last Name *
Occupation (For eg, Doctor, Nurse, Pharmacist, etc) *
Organisation Name *
Email *
Phone Number *

Reporter Information

Salutation
First Name
Last Name *
Your relationship to the patient *
Can we follow up with you if we have additional questions or need to respond to your request?

Reporter's Contact Information

Email Address *
Phone
Address
Country

Patient Information

Patient Initials *
Date of Birth
Gender at birth *
Height (Cm)
Weight (Kg)
Please provide any relevant medical history, do not use the patient’s name or any personally identifiable information (email, address, phone number).

Healthcare Provider

Can we follow up with your healthcare provider if we have additional questions or need to respond to your request?

Healthcare Provider's Detail

Salutation
First Name
Last Name *
Occupation (For eg, Doctor, Nurse, Pharmacist, etc) *
Organisation Name *
Email *
Phone Number *

Reporter Information

Salutation
First Name
Last Name *
Occupation (For eg, Doctor, Nurse, Pharmacist, etc) *
Can we follow up with you if we have additional questions and to respond to your request?

Contact Information

Organisation Name *
Email *
Phone Number *

Patient Information

Patient Initials *
Date of Birth
Gender at birth *
Height (Cm) *
Weight (Kg)
Please provide any relevant medical history, do not use the patient’s name or any personally identifiable information (email, address, phone number).

Report an Adverse Event

What is the name of Medication/Device? (To include the strength and formulation if available. For eg, Paracetamol 500mg Tablets) *
Batch Number/Lot Number *
Expiration Date
What is the reason for taking/using the Medication/Device?
How is the medication being taken? (For example, take 2 tablets of 100mg tablets three times daily Or Inject intravenously 200mg four times daily)
Start Date of Medication/Device usage
End Date of Medication/Device usage
Action taken with Medication/Device (For example, Temporary Stop, Discontinued, Reduced, Increased, None, Not Applicable or Unknown) *
Unique Device Identifier, if applicable.
Device Operator *
What is the adverse event? *
Start Date of the adverse event
End Date of the adverse event
Event Duration
Event outcome *
Select applicable criteria for this event, leave blank if none are applicable
Do you think this event is caused by this medication / device?
Did the symptoms improve after the medication adjustment?
Was the medication/device usage restarted?
Is there any additional information you would like to share regarding the adverse event(s)? Please include any over the counter medication, vitamins, or supplements you are taking.

Report a Quality Issue

What is the name of Medication/Device? (To include the strength and formulation if available. For eg, Paracetamol 500mg Tablets) *
Batch Number / Lot Number *
Expiration Date
Additional information
Pharmacy Name
Wholesaler Name
Who administered the product? *
How many times have you previously administered / used the product? *
How were you trained to use this product? *
When did you notice the problem/defect?
Defect Start Date
Number of defective units
Tell us about your complaint. Please provide details such as:
- A description of the circumstances that led to the discovery of the product defect.
- How long have you experienced the issue with the product?
- If use or user error relates to the Product Quality Complaint. *
Is the sample available for return?
Is the Needle exposed (if the product is an injectable)?

Note: Please review the details you have entered and confirm they are correct before submitting.


Legal Disclaimer

We are legally obligated to collect and, when necessary, report adverse event data to health authorities. To comply with these requirements, any personal information that could identify you will be pseudonymized in our adverse event database.

If you have experienced an adverse event or suspect you might be, please consult a healthcare professional.

Vendor Information

Reporter Information

Healthcare Provider

Healthcare Provider's Detail

Reporter Information

Reporter's Contact Information

Patient Information

Healthcare Provider

Healthcare Provider's Detail

Reporter Information

Contact Information

Patient Information

Report an Adverse Event

Report a Quality Issue


Note: Please review the details you have entered and confirm they are correct before submitting.


Legal Disclaimer

We are legally obligated to collect and, when necessary, report adverse event data to health authorities. To comply with these requirements, any personal information that could identify you will be pseudonymized in our adverse event database.

If you have experienced an adverse event or suspect you might be, please consult a healthcare professional.

Vendor Information

Reporter Information

Healthcare Provider

Healthcare Provider's Detail

Reporter Information

Reporter's Contact Information

Patient Information

Healthcare Provider

Healthcare Provider's Detail

Reporter Information

Contact Information

Patient Information

Report an Adverse Event

Report a Quality Issue


Note: Please review the details you have entered and confirm they are correct before submitting.

  • Skywaves Industrial Building. 30 Lor Ampas. #02-01. Singapore 328783
  • +65 65920680 (Main Line)
  • +65 64420213 (Fax)
  • info@pillsandpokes.sg

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OUR MAIN OFFICE

HOME

  • Skywaves Industrial Building. 30 Lor Ampas. #02-01. Singapore 328783
  • +65 65920680 (Main Line)
  • +65 64420213 (Fax)
  • info@pillsandpokes.sg

FOLLOW US ON SOCIAL MEDIA

Linkedin Facebook Twitter Instagram

HOME

OUR MAIN OFFICE

  • Skywaves Industrial Building. 30 Lor Ampas. #02-01. Singapore 328783
  • +65 65920680 (Main Line)
  • +65 64420213 (Fax)
  • info@pillsandpokes.sg

OUR MAIN OFFICE

HOME

FOLLOW US ON SOCIAL MEDIA

Linkedin Facebook Twitter Instagram

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