+3@A7=< =@+%"*$)'-@3>=@B7<5 =42D3@A3@C5'3/1B7=< 0G3/:B61/@3&@=43AA7=</:A (National Coordination Centre-Pharmacovigilance Programme of India) Ministry of Health & Family Welfare, Government of India Sector-23, Raj Nagar, Ghaziabad-201002 Reg. No. /IPD No. /OPD No. /CR No. : &) $) $%'#) %$ &/B73<B <7B7/:A ......... 2. Age at the time of Event or Date of Birth ______________ # JJ %B63@ J ,3756B........!5A AMC Report No. : Worldwide Unique No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