Product Quality Defects Last Updated on April 10, 2023 1.Reporter Information Title (please select) Dr. Mr. Mrs. Ms. Full Name(required) Contact Number Mobile(required) Email Address(required) Address City(required) Country 2.Product Information Please use product label to fill out information required in this section Product Name (as on label)(required) Strength (as on label) Active Ingredients Dosage Form (e.g. Tab, Cap, Inj, etc.) Packaging (eg. 60ml, 30,s, etc.) Reg/Enlist No. (as on label) Batch No (as on label)(required) Manufacturing Date (as on label) Expiry Date (as on label) Manufacturer Name (as on label) Where from you get/purchased this product (Pharmacy / Hospital Name) 3.Quality Defect Information Please give details of the defect and any related information (required) Have you reported this defect to any other forum? Yes No If yes please mention name of forum/ Institution? Is sample available for further investigation? Yes No Do you agree to share your contact details for follow up? Yes No Before submitting, please carefully review that all required information has been provided. Submit Pages: 1 2
