HOMECARE
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HOMECARE
PRODUCTS
PROJECTS
BRANDS
SERVICES
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Nature of Complaint
Select nature of complaint
Product Related
Service Related
Product
Pharmaceutical Products
Medical Device
Other (Please Specify)
Product Name
Reference No
Batch No
Patient Injury / Harm
Yes
No
Unkown
Description of Issue
Reported By
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Patient
Customer
Other (Please Specify)
Name
Gender
Male
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Phone No
Email
Address
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