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ADrug / Vaccine / OTC Name Generic or Trade Batch/Lot No. Expiry Date Formulation e.g. tablet injection Route e.g. oral IV Total Daily Dose e.g. 20mg daily Course Began dd/mm/yy Ended Gestation Weeks of Exposure e.g. wk 28 - wk 32 Indication for Treatment Note Please indicate with an asterix the medication s /vaccine s that were considered related to any adverse events reported in section 3 if applicable Pregnancy Initial Notification Form Version 01 Effective 24 March 2010 page 1 of 3 If the...
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