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. Initial details

Is this a serious case?

Please select is this a serious case?

II. 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

III. Health details

Reason(s) for taking medicine(s)/ vaccine(s)? 0/5000

Please enter reason(s) for taking medicine(s)/ vaccine(s), must not exceed 5000 characters length

Medicines/ Vaccines advised by

Please select medicines/ Vaccines advised by

IV. Side effect details

Started date

Please select started date

Still continuing?

Please select still continuing?

Describe the details of side effect and what treatments were taken to manage the side effect0/5000

Please describe the details of side effect and what treatments were taken to manage the side effect, must not exceed 5000 characters length

V. Medicine/ Vaccine taken/ taking details

Blank

Medicine/ Vaccine name

Please enter medicine/ vaccine name, must not exceed 100 characters length

Manufacturer name

Manufacturer name can not exceed 100 characters in length

Manufacturing license no.?

Please enter manufacturing license no., must not exceed 50 characters length

Batch/ Lot no.?

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

Expiry date

Please select expiry date

Quantity taken?

Please enter quantity taken, must not exceed 50 characters length

Dosage form

Please select dosage form

Started taking date

Please select started taking date

Stopped taking date

Please select stopped taking date

VI. 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

Medicine/ Vaccine side effect reporting form Medicine/ Vaccine side effect reporting form

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