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NEW ALLERGIC DRUG REACTION REPORTING FORM See instructions on how to use this form on reverse side. User’s last name First name File Number Year Month Day Sex Date of birth M F Health Insurance Number

NEW ALLERGIC DRUG REACTION REPORTING FORM See instructions on how to use this form on reverse side. User’s last name First name File Number Year Month Day Sex Date of birth M F Health Insurance Number

NEW ALLERGIC DRUG REACTION REPORTING FORM See instructions on how to use this form on reverse side. User’s last name First name File Number Year Month Day Sex Date of birth M F Health Insurance Number

NEW ALLERGIC DRUG REACTION REPORTING FORM User’s last name First name File Number Year Month Day Sex Date of birth M F Health Insurance Number Year Month Expiry date SUSPECTED DRUGS (List in order of

NEW ALLERGIC DRUG REACTION REPORTING FORM User’s last name First name File Number Year Month Day Sex Date of birth M F Health Insurance Number Year Month Expiry date SUSPECTED DRUGS (List in order of

NEW ALLERGIC DRUG REACTION REPORTING FORM User’s last name First name File Number Year Month Day Sex Date of birth M F Health Insurance Number Year Month Expiry date SUSPECTED DRUGS (List in order of

NEW ALLERGIC DRUG REACTION REPORTING FORM User’s last name First name File Number Year Month Day Sex Date of birth M F Health Insurance Number Year Month Expiry date SUSPECTED DRUGS (List in order of