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Impax Adverse Event and Product Complaint Report Form
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Your Details
Date of Report
MM
/
DD
/
YYYY
Date Aware of Adverse Event and/or Product Complaint
*
MM
/
DD
/
YYYY
Your Name
*
Your answer
Your Contact Telephone Number or Email
*
Your answer
Impax Drug Details
Drug Name(s)
*
Your answer
Adverse Event or Product Complaint Details
*
Your answer
Patient Details
Patient Initials
Your answer
Date of Birth, Age or Age Category
Your answer
Sex
Male
Female
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Reporter Details
Person who provided you with details, if different from patient
Reporter Name
Your answer
Reporter Telephone No
Your answer
Reporter Email
Your answer
Reporter Address
Your answer
Reporter Type
Healthcare Professional
Patient
Impax Employee/Contractor
Other:
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