{"id":117,"date":"2026-03-02T14:05:15","date_gmt":"2026-03-02T13:05:15","guid":{"rendered":"https:\/\/dev.snark-gfx.com\/ar\/pharmacovigilance\/pharmacovigilance-form\/"},"modified":"2026-04-02T08:39:00","modified_gmt":"2026-04-02T06:39:00","slug":"pharmacovigilance-form","status":"publish","type":"page","link":"https:\/\/dev.snark-gfx.com\/ar\/pharmacovigilance\/pharmacovigilance-form\/","title":{"rendered":"Pharmacovigilance Form \u0627\u0633\u062a\u0645\u0627\u0631\u0629 \u0627\u0644\u062a\u064a\u0642\u0638 \u0627\u0644\u062f\u0648\u0627\u0626\u064a"},"content":{"rendered":"\n<div class=\"wp-block-contact-form-7-contact-form-selector\">\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f400-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"400\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/ar\/wp-json\/wp\/v2\/pages\/117#wpcf7-f400-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"400\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.5\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f400-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/><input type=\"hidden\" name=\"_wpcf7cf_hidden_group_fields\" value=\"[]\" \/><input type=\"hidden\" name=\"_wpcf7cf_hidden_groups\" value=\"[]\" \/><input type=\"hidden\" name=\"_wpcf7cf_visible_groups\" value=\"[]\" \/><input type=\"hidden\" name=\"_wpcf7cf_repeaters\" value=\"[]\" \/><input type=\"hidden\" name=\"_wpcf7cf_steps\" value=\"{}\" \/><input type=\"hidden\" name=\"_wpcf7cf_options\" value=\"{&quot;form_id&quot;:400,&quot;conditions&quot;:[{&quot;then_field&quot;:&quot;notificateur&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;notificateurdiff&quot;,&quot;operator&quot;:&quot;not empty&quot;,&quot;if_value&quot;:&quot;&quot;}]}],&quot;settings&quot;:{&quot;animation&quot;:&quot;yes&quot;,&quot;animation_intime&quot;:200,&quot;animation_outtime&quot;:200,&quot;conditions_ui&quot;:&quot;normal&quot;,&quot;notice_dismissed&quot;:false}}\" \/>\n<\/fieldset>\n<div class=\"zoneform\">\n\t<h2>CLAIMANT\n\t<\/h2>\n\t<div class=\"wp-block-columns zoneform\">\n\t\t<div class=\"wp-block-column\">\n\t\t\t<p><label> Date <span class=\"wpcf7-form-control-wrap\" data-name=\"date-declarant\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"date-declarant\" \/><\/span> <\/label><br \/>\n<label> Quality <span class=\"wpcf7-form-control-wrap\" data-name=\"statut-declarant\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"statut-declarant\"><option value=\"Select\">Select<\/option><option value=\"Patient\">Patient<\/option><option value=\"Pharmacy\">Pharmacy<\/option><option value=\"Doctor\">Doctor<\/option><option value=\"Healthcare Facility\">Healthcare Facility<\/option><option value=\"Wholesaler-Distributor\">Wholesaler-Distributor<\/option><option value=\"Others\">Others<\/option><\/select><\/span> <\/label><br \/>\n<label> Entity \/ Company<span class=\"wpcf7-form-control-wrap\" data-name=\"company-declarant\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"company-declarant\" \/><\/span> <\/label><br \/>\n<label> Country <span class=\"wpcf7-form-control-wrap\" data-name=\"country-declarant\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"country-declarant\" \/><\/span> <\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"wp-block-column\">\n\t\t\t<p><label> Last Name \/ Fist Name <span class=\"wpcf7-form-control-wrap\" data-name=\"collaborateur-declarant\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"collaborateur-declarant\" \/><\/span> <\/label><br \/>\n<label> Adress <span class=\"wpcf7-form-control-wrap\" data-name=\"adress-declarant\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"adress-declarant\" \/><\/span> <\/label><br \/>\n<label> Phone Number <span class=\"wpcf7-form-control-wrap\" data-name=\"phone-declarant\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"phone-declarant\" \/><\/span> <\/label><br \/>\n<label> Email <span class=\"wpcf7-form-control-wrap\" data-name=\"mail-declarant\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"mail-declarant\" \/><\/span> <\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"zoneform\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"notificateurdiff\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"notificateurdiff[]\" value=\"Reporting party is different from the claimant\" \/><span class=\"wpcf7-list-item-label\">Reporting party is different from the claimant<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div data-id=\"notificateur\" data-orig_data_id=\"notificateur\"  class=\"\" data-class=\"wpcf7cf_group\">\n\t<div class=\"zoneform\">\n\t\t<h2>REPORTING PARTY\n\t\t<\/h2>\n\t\t<div class=\"wp-block-columns\">\n\t\t\t<div class=\"wp-block-column\">\n\t\t\t\t<p><label> Quality <span class=\"wpcf7-form-control-wrap\" data-name=\"statut-notificateur\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"statut-notificateur\"><option value=\"Select\">Select<\/option><option value=\"Patient\">Patient<\/option><option value=\"Pharmacy\">Pharmacy<\/option><option value=\"Doctor\">Doctor<\/option><option value=\"Healthcare Facility\">Healthcare Facility<\/option><option value=\"Wholesaler-Distributor\">Wholesaler-Distributor<\/option><option value=\"Others\">Others<\/option><\/select><\/span> <\/label><br \/>\n<label> Entity \/ Company <span class=\"wpcf7-form-control-wrap\" data-name=\"company-notificateur\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"company-notificateur\" \/><\/span> <\/label><br \/>\n<label> Country <span class=\"wpcf7-form-control-wrap\" data-name=\"country-notificateur\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"country-notificateur\" \/><\/span> <\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"wp-block-column\">\n\t\t\t\t<p><label> Last Name \/ Fist Name <span class=\"wpcf7-form-control-wrap\" data-name=\"collaborateur-notificateur\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"collaborateur-notificateur\" \/><\/span> <\/label><br \/>\n<label> Adress <span class=\"wpcf7-form-control-wrap\" data-name=\"adress-notificateur\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"adress-notificateur\" \/><\/span> <\/label><br \/>\n<label> Phone Number <span class=\"wpcf7-form-control-wrap\" data-name=\"phone-notificateur\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"phone-notificateur\" \/><\/span> <\/label><br \/>\n<label> Email <span class=\"wpcf7-form-control-wrap\" data-name=\"mail-notificateur\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"mail-notificateur\" \/><\/span> <\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"zoneform\">\n\t<h2>IDENTIFICATION OF THE PRODUCT\n\t<\/h2>\n\t<div class=\"wp-block-columns\">\n\t\t<div class=\"wp-block-column\" style=\"flex-basis:50%\">\n\t\t\t<p><label> Product Name and Pharmaceutical Form <span class=\"wpcf7-form-control-wrap\" data-name=\"denomination\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"denomination\" \/><\/span> <\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"wp-block-column\">\n\t\t\t<p><label> Batch Number <span class=\"wpcf7-form-control-wrap\" data-name=\"lot\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"lot\" \/><\/span> <\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"wp-block-column\">\n\t\t\t<p><label> Expiration Date <span class=\"wpcf7-form-control-wrap\" data-name=\"premption\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"premption\" \/><\/span> <\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"zoneform\">\n\t<h2>PATIENT\n\t<\/h2>\n\t<div class=\"wp-block-columns\">\n\t\t<div class=\"wp-block-column\">\n\t\t\t<p><label> Initials <span class=\"wpcf7-form-control-wrap\" data-name=\"init\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"init\" \/><\/span> <\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"wp-block-column\">\n\t\t\t<p><label> Sex <span class=\"wpcf7-form-control-wrap\" data-name=\"sex\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"sex\"><option value=\"S\u00e9l\u00e9ctionner\">S\u00e9l\u00e9ctionner<\/option><option value=\"Female\">Female<\/option><option value=\"Male\">Male<\/option><option value=\"Other\">Other<\/option><\/select><\/span> <\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"wp-block-column\">\n\t\t\t<p><label> Age <span class=\"wpcf7-form-control-wrap\" data-name=\"age\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"age\" \/><\/span> <\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"zoneform\">\n\t<h2>SUBJECT\n\t<\/h2>\n\t<p><label> Detailed Description <span class=\"wpcf7-form-control-wrap\" data-name=\"objet\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"objet\"><\/textarea><\/span> <\/label>\n\t<\/p>\n<\/div>\n<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Envoyer\" \/>\n<\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n<\/div>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":75,"menu_order":1,"comment_status":"closed","ping_status":"closed","template":"","meta":{"inline_featured_image":false,"tableau":"","footnotes":""},"class_list":["post-117","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/dev.snark-gfx.com\/ar\/wp-json\/wp\/v2\/pages\/117","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/dev.snark-gfx.com\/ar\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/dev.snark-gfx.com\/ar\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/dev.snark-gfx.com\/ar\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/dev.snark-gfx.com\/ar\/wp-json\/wp\/v2\/comments?post=117"}],"version-history":[{"count":3,"href":"https:\/\/dev.snark-gfx.com\/ar\/wp-json\/wp\/v2\/pages\/117\/revisions"}],"predecessor-version":[{"id":401,"href":"https:\/\/dev.snark-gfx.com\/ar\/wp-json\/wp\/v2\/pages\/117\/revisions\/401"}],"up":[{"embeddable":true,"href":"https:\/\/dev.snark-gfx.com\/ar\/wp-json\/wp\/v2\/pages\/75"}],"wp:attachment":[{"href":"https:\/\/dev.snark-gfx.com\/ar\/wp-json\/wp\/v2\/media?parent=117"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}