Patient name or initial:

    Age (Optional):

    Sex (Optional):

    Product Name

    Adverse event including relevant teststlab data and dates:

    Other relevant history, including preexisting medical conditions (diagnosis, allergies, pregnancy, hepatic, renal etc) (Optional):

    Reporter name:

    Profession (Specialty) (Optional):

    Address (Optional):

    E-mail:

    Phone / Mobile:

    Global Pharmacovigilance Contact Information:

    You can report a suspected side effect in a number of ways:

    • By using our online form.
    • By Phone or Email:

    Name: Norah Ibrahim AlSuhaibani

    Title: Qualified person for pharmacovigilance  (QPPV)

    Mobile: 0530408553

    Direct: 0112931773

    Ext: 113

    Email: pv@alphapharma.com.sa