ADRMS - IPC

Mobile Verification

Mobile no.

Please enter a valid mobile no.

One Time Password

Please click on Get OTP link to receive a 6 digit long OTP on your mobile, enter that OTP here

I. Patient details

Are you a patient?

Yes No, Somebody else is a patient

Please select whether you are a patient or somebody else is a patient

First name

First name must not exceed 50 characters length

Last name

Last name must not exceed 50 characters length

Initials?

Please enter initials

Date of birth/ Age

If you know date of birth then please select date of birth or else select age

Gender

Please select gender

Weight

kg

Address0/150

Address can not exceed 1000 characters in length

Pin code

Please enter a valid pin code

District

Please select district

State

Please select state

Country

Please select country

II. Adverse event details

Date of event

Please select started date

Location of event

Describe the details of adverse event0/5000

Please describe the details of side effect, must not exceed 5000 characters length

Device operator

Was device return to local supplier

Other relevant information0/2500

Other relevant information must not exceed 2500 characters length

III. Medical device details

Device name

Please enter device name, must not exceed 100 characters length

Model no.

Please enter model no., must not exceed 50 characters length

Serial no.

Please enter serial no., must not exceed 50 characters length

Batch/ Lot no.

Please enter batch/ lot no., must not exceed 50 characters length

Software version

Please enter software version, must not exceed 50 characters length

Manufacture date

Please select manufacture date

Installation date

Please select installation date

Expiry date

Please select expiry date

Implantation date

Please select implantation date

Device manufacturer name

Please eneter device manufacturer name, must not exceed 60 characters length

Local supplier name

Please eneter local supplier name, must not exceed 60 characters length

IV. Upload relevant document

Document title

Document title can not exceed 60 characters in length. Also, this becomes a required field if document upload field is populated

Upload document

Choose file... Browse

Upload document file can be of PDF/JPG/MP4 type, and can not exceed 10 MB in size. Also, this becomes a required field if document title field is populated