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    REPORT OF LACK OF EFFICACY OF PHARMACEUTICAL PRODUCT
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    ADVERSE DRUG REACTION REPORT
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    For the transfer of information related to the above cases, as well as for consultation on these issues, please contact the pharmacovigilance department of Kusum Pharm.
    Kusum Healthcare Pvt. Ltd. Branch Office
    Regd. Office:
    Units 2405 and 2406, 24/F The Orient Square, F. Ortigas Jr. Road, Ortigas Center, Pasig City, Metro Manila Philippines 1605
    Tel:
    +63 2 (8) 245-9046; +63 2 (8) 248-9048; +63 2 (8) 245-9047; +63 2 (8) 355-5786;
    Email:
    [email protected]
    CIN:
    U65929DL1997PTC085780
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    All information that you provide to us is confidential and not subject to disclosure, except as provided by law.
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    Online application form

    *These fields are required.

    INFORMATION ABOUT A PATIENT
    Name
    Surname
    Sex:
    Day of birth
    Year of birth
    Weight (kg)
    Height (sm)
    Hepatic disease:
    Renal disease:
    Pregnancy:
    Term
    Allergy:
    SUSPECTED PHARMACEUTICAL PRODUCT(-S) (SPP)
    Brand name
    International non-proprietary name
    Pharmaceutical form
    Batch No
    Start date (dd/mm/yyyy)
    End date (dd/mm/yyyy)
    Dosage, frequency and method of administration ...
    Prescribed for...
    Add another appointment
    OTHER PHARMACEUTICAL PRODUCTS (administered in the last 3 months)
    Brand name
    International non-proprietary name
    Pharmaceutical form
    Batch No
    Start date (dd/mm/yyyy)
    End date (dd/mm/yyyy)
    Dosage, frequency and method of administration ...
    Prescribed for...
    Add another appointment
    LACK OF EFFICACY (LOE)
    Description of lack of efficacy signs (including any results of relevant supportive laboratory tests and other investigations) .
    Start date of LOE (dd/mm/yyyy)
    End date of LOE (dd/mm/yyyy)
    Did changing of SPP result in LOE disappearance:
    Did rechallenge of SPP cause repeated LOE:
    Measures taken:
    Specify the name
    Pharmacological therapy of LOE (if any):
    Text...
    Result:
    Indicate recovery with consequences
    Measures of the seriousness:
    Specify
    INFORMATION ABOUT A REPORTER
    Full name
    Phone
    Occupation
    Health care institution
    Address
    Email
    Date of LOE information receipt
    Filling date (dd / mm / yyyy)
    Online application form

    *These fields are required.

    INFORMATION ABOUT A PATIENT
    Name
    Surname
    Sex:
    Day of birth
    Year of birth
    Weight (kg)
    Height (sm)
    Hepatic disease:
    Renal disease:
    Pregnancy:
    Term
    Allergy:
    SUSPECTED PHARMACEUTICAL PRODUCT(-S) (SPP)
    Brand name
    International non-proprietary name
    Pharmaceutical form
    Batch No
    Start date (dd/mm/yyyy)
    End date (dd/mm/yyyy)
    Dosage, frequency and method of administration ...
    Prescribed for...
    Add another appointment
    OTHER PHARMACEUTICAL PRODUCTS (administered in the last 3 months)
    Brand name
    International non-proprietary name
    Pharmaceutical form
    Batch No
    Start date (dd/mm/yyyy)
    End date (dd/mm/yyyy)
    Dosage, frequency and method of administration ...
    Prescribed for...
    Add another appointment
    SUSPECTED ADVERSE DRUG REACTION(-S) (ADR)
    Description of the ADR (including any results of relevant supportive laboratory tests and other investigations) .
    Start date of ADR (dd/mm/yyyy)
    End date of ADR (dd/mm/yyyy)
    Did the ADR disappear after the drug was discontinued:
    Did rechallenge of SPP cause repeated ADR:
    Measures taken:
    Specify the name
    Pharmacological therapy of ADR (if any):
    Text...
    Result:
    Indicate recovery with consequences
    Measures of the seriousness:
    Specify
    INFORMATION ABOUT A REPORTER
    Full name
    Phone
    Occupation
    Health care institution
    Address
    Email
    Date of LOE information receipt
    Filling date (dd / mm / yyyy)
    Your request was successfully sent
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    Phone
    Email
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