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Address:
1139 Yates Street, Victoria, BC, V8V 3N2
Phone:
(250) 386-5100
Mail:
sukhi@lallicare.ca
(250) 386-5100
sukhi@lallicare.ca
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Report an adverse reaction
A. Patient Information
Patient Identifier
Age at time of reaction
Sex
Male
Female
Height
Weight
B. Adverse Reaction
Outcome attributed to adverse reaction(check all that apply)
Death
Life Threatening
Hospitalization
Hospitalization-Prolonged
Disability
Congenital Malformation
Required intervention to prevent damage
Other…
Enter other…
Date and time of reaction
Date and time of reaction: Date
Date and time of reaction: Time
Date of this report
Describe reaction or problem
Relevant tests
C, SUSPECTED DRUG PRODUCTS(S)
1. Name (give labelled strength & manufacturer, if known).
2. Dose, frequency, & route used
3. Therapy dates(if known, give duration)
4. Indication for use of suspected drug product
5. Reaction abated after use stopped or dose reduced.
Yes
No
Dosen't Apply
6. Lot # (if known)
7. Exp. Date
8. Reaction reappeared after reintroduction
Yes
No
Dosen't Apply
9. Concomitant drugs(name, dose, frequency and route used) and therapy dates
10. Treatment of adverse reaction
D. Reporter
1. Name, address, email, & phone number.
2. Health professional?
Yes
No
3. Occupation
4. Also reported to manufacturer?
Yes
No
E. SUSPECT MEDICAL DEVICE
1. Brand name
2. Type of device
3. Manufacturer name & address
4. Operator of device
Health Professional
Lay user/patient
Other
5. Expiration date
6. If implanted, give date
7. If explanted, give date
Model #
Serial #
Catalog #
Lot #
Other
8. Device available for evaluation? (Do not send)
Yes
No
9. Concomitant medical products and therapy dates (exclude treatment of event)
Request a Refill
First Name
Last Name
RX Number
Email
Comments
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Awesome people. The Lalli family and their staff are warm wonderful people always willing to help.
Stephen Mendelsohn
You can get $20 for your script from STS Pain pharmacy compared to nothing from these guys.
MIchelle Oulette
These people are a special bunch...really, really awesome.
Marlo Southwell