Reporter Information

Name:

Address:

City:  State:  Zip Code:

Phone:

Alternative Phone Number:


Fax:

Patient Information
Name:  Initials:  

Gender:    Weight:   

Date Of Birth:   Age

Age Group:

Race:
Adverse Event(s) Details
Signs, Symptoms or Diagnosis

Drug Used During Symptoms
A=Amphotec
I=Infergen
RT=Ribavirin Tablets
RC=Ribavirin Capsules
RP=RibaPak

 Date of Onset

Outcome
R=Recovered
I=improved
C=Continue

Drug( Please verify Drug is a Three Rivers Pharmaceuticals medication )                               Action Taken with Medication

Amphotec: 
Infergen:
Ribavirin Tablets:
Ribavirin Capsules:
RibaPak: