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Kelun-Biotech:No. 666 Xinhua Avenue Chengdu Cross-Strait Science and Technology Industry Development Park Wenjiang District, Chengdu Sichuan Province, PRC

KLUS PHARMA:101 College Rd. East, 2nd Floor, Princeton Forrestal Center, Princeton, NJ 08540

Clinical research center (Beijing):Room 403, Building D, Yonggui Center, No. 45 Guangqumennei Street, Dongcheng District; Beijing

Clinical research center (Shanghai): Unit 1904-1906, No. 763, Hong Kong Prosperity Tower, Mengzi Road, Huangpu, Shanghai



Recruitment of,400-688-7002

Feedback on,400-688-7002

    Compliance Reporting Hotline:; 028-82053800

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Report list of adverse drug reactions/events

Information of reporter

Your Surname:

Your Occupation:

Your Province of Domicile:

Information of Patient

First Alphabet of the Name of Patient:

Gender of Patient:

Height of Patient:

Weight of Patient:

Date of Birth of Patient:

Drug Indication:

Information of Drug

Name of Suspected Drug:

Drug Marketing Authorization Holder:

Production Batch Number of Drug:

Medication Frequency:

Amount per Dose:

Treatment Starting Date:

Treatment End Date:(Leave here blank if still on medication):

Other Medications Used Concurrently:

(Drugs that have been discontinued within 14 days prior to the occurrence of the adverse reaction or that are ongoing when the adverse reaction occurs, excluding the drug used for the treatment of the adverse reaction)(Leave here blank if no other medication)

Information on Adverse Reaction

Adverse Reaction Occurring Date:

Adverse Reaction Terms:

Clinical diagnosis is preferred. If no diagnosis, please provide major symptoms

Current Conditions:

Description of the Course of Adverse Reaction:

Be exhaustive if possible: patient's information, allergy history, medication information, diagnosis and treatment, clinical laboratory reports, etc. can be filled in. Please also fill in information on pregnancy and breastfeeding if applicable.

Other Information

Other Information to be submitted (Attachments such as patient’s records and examination reports can be inserted below):

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Accepting Follow-up or Not:

contact information: