COMPLAINT REQUEST FORM
STATUS
SAVE
UPDATE
GUIDE
Registration Guidelines
All fields marked with asterik (*) are mandatory.
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Complaint Type :
*
Complainant Type :
Search Complainant Type
Please read OM dated 22.11.2021 before filling this form
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Complaint Source:
Please Enter Complainant Type
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Supporting Document:
COMPLAINANT'S INFORMATION:
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Complainant Type:
--
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Name:
*
Complainant Type:
--
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Name:
*
Other PMRU Name:
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State:
Search State Here
District:
Search District Here
PIN Code:
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Address:
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Mobile No.:
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E-mail Address:
COMPLAINT DETAILS:
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Brand:
If no brand name found please select
Other
option
Select Brand:
NONE
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Formulation:
Formulation:
Search Formulation Here
Select Brand
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Dosage Form:
Dosage Form:
Search Dosage Form Here
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Strength:
Strength:
Search Strength Here
Pack Size:
Search Unit Here
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Composition of Formulation:
Composition of Formulation:
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Existing MRP:
Previous MRP:
Price Charged by Retailer:
Batch No. Of Formulation:
Month & Year of Manufacturing:
Month & Year of Expiry:
Notification No.:
Notification Date:
Notified Ceiling Price/ Retail Price/ MRP.:
*
Composition of Formulation:
Composition of Formulation:
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Composition of Formulation:
Composition of Formulation:
Batch No. Of Formulation:
Month & Year of Manufacturing:
Month & Year of Expiry:
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MRP Of Formulation:
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Date of Launch of New Drug:
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Composition of Formulation:
Composition of Formulation:
*
:
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Address:
Contact No:
Email Address:
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State:
Search State Here
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District:
Search District Here
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Pin Code:
Provide details of any one of the Chemist/Retailer/Pharmacist where medicine is not available in your area
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Name of Entity Who Refused:
Manufacturer
Marketer
Importer
Stockist/Distributor
Retailer
EXISTING MANUFACTURER DETAILS:
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Details of Scheduled Formulation manufactured by the Existing Manufacturer:
Search Scheduled Component Here
Supporting Document:
MANUFACTURER DETAILS:
*
Name of Manufacturer:
Search Manufacture Name Here
If no manufacturer name found please select
Other
option
*
Address of Manufacturer:
Search State Here
Search District Here
E-Mail Address of Manufacturer:
Contact No. of Manufacturer:
Is Manufacturer same as Marketer:
MARKETER DETAILS:
*
Name of Marketer:
Search Marketer Name Here
If no marketer name found please select
Other
option
*
Address of Marketer:
Search State Here
Search District Here
E-Mail Address of Marketer:
Contact No. of Marketer:
CHEMIST DETAILS:
Name of Chemist:
Address of Chemist / Retailer from whom purchased:
Date of Purchase:
GSTIN No:
ENCLOSURES:
Upload copy of the strip/label:
Upload copy of the cash memo:
Upload of at least any one document is mandatory
Whether request for supply of formulation given in writing (Y/N):
Yes
No
Upload Document:
Whether refusal is communicated in writing (Y/N):
Yes
No
Upload Document:
ANY OTHER INFORMATION:
Enter any other comments:
Any Other Additional information:
Previous complaint number, if any:
Previous complaint date, if any:
Captcha Code:
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BRAND SUGGESTION
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This medicine should be taken in consultation with doctor. NPPA will not responsible for the same