- Indian Pharmacopoeia Commission
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All fields marked with an asterisk * are mandatory

Mobile Verification

Please enter a valid mobile no.
Please click on Get OTP link to receive a 6 digit long OTP on your mobile, enter that OTP here

I. प्रारंभिक विवरण

Please select is this a serious case?
Please select seriousness reasons that apply

II. रोगी का विवरण

Please select whether you are a patient or somebody else is a patient
First name must not exceed 50 characters length
Last name must not exceed 50 characters length
Please enter initials
If you know date of birth then please select date of birth or else select age
Please select date of birth
Please enter age
Please select age unit
Please select gender
kg
Address can not exceed 1000 characters in length
Please enter a valid pin code
Please select district
Please select state
Please select country
Please select how do you know the patient?
Please enter relation of family member, must not exceed 50 characters length
Please enter others, must not exceed 50 characters length

III. स्वास्थ्य का विवरण

Please enter reason(s) for taking medicine(s)/ vaccine(s), must not exceed 5000 characters length
Please select medicines/ Vaccines advised by

IV. दुष्प्रभाव का विवरण

Please select started date
Please select still continuing?
Please select stopped date
Please describe the details of side effect and what treatments were taken to manage the side effect, must not exceed 5000 characters length

V. दवा(दवाएँ) अथवा टीका(टीके) को ली जा रही अथवा ली जा चूंकि का विवरण

Please enter medicine/ vaccine name, must not exceed 100 characters length
Manufacturer name can not exceed 100 characters in length
Please enter manufacturing license no., must not exceed 50 characters length
Please enter batch/ lot no., must not exceed 50 characters length
Please select expiry date
Please enter quantity taken, must not exceed 50 characters length
Please select dosage form
Please enter others, must not exceed 50 characters length
Please select started taking date
Please select stopped taking date

VI. प्रासंगिक दस्तावेज़(दस्तावेजों) को अपलोड करें

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