{"id":772,"date":"2020-07-10T14:15:15","date_gmt":"2020-07-10T14:15:15","guid":{"rendered":"http:\/\/cipla.co.ke\/?page_id=772"},"modified":"2026-03-27T13:12:55","modified_gmt":"2026-03-27T10:12:55","slug":"contact","status":"publish","type":"page","link":"https:\/\/ke.cipla.africa\/en\/contact\/","title":{"rendered":"Contact"},"content":{"rendered":"[vc_row type=&#8221;full_width_background&#8221; full_screen_row_position=&#8221;middle&#8221; column_margin=&#8221;60px&#8221; column_direction=&#8221;default&#8221; column_direction_tablet=&#8221;default&#8221; column_direction_phone=&#8221;default&#8221; scene_position=&#8221;center&#8221; top_padding=&#8221;5%&#8221; constrain_group_1=&#8221;yes&#8221; bottom_padding=&#8221;5%&#8221; text_color=&#8221;dark&#8221; text_align=&#8221;left&#8221; row_border_radius=&#8221;none&#8221; row_border_radius_applies=&#8221;bg&#8221; row_position_desktop=&#8221;default&#8221; row_position_tablet=&#8221;inherit&#8221; row_position_phone=&#8221;inherit&#8221; overflow=&#8221;visible&#8221; overlay_strength=&#8221;0.3&#8243; gradient_direction=&#8221;left_to_right&#8221; shape_divider_position=&#8221;bottom&#8221; bg_image_animation=&#8221;none&#8221; gradient_type=&#8221;default&#8221; shape_type=&#8221;&#8221;][vc_column column_padding=&#8221;no-extra-padding&#8221; column_padding_tablet=&#8221;inherit&#8221; column_padding_phone=&#8221;inherit&#8221; column_padding_position=&#8221;all&#8221; flex_gap_desktop=&#8221;10px&#8221; column_element_direction_desktop=&#8221;default&#8221; column_element_spacing=&#8221;default&#8221; desktop_text_alignment=&#8221;default&#8221; tablet_text_alignment=&#8221;default&#8221; phone_text_alignment=&#8221;default&#8221; background_color_opacity=&#8221;1&#8243; background_hover_color_opacity=&#8221;1&#8243; column_backdrop_filter=&#8221;none&#8221; column_shadow=&#8221;none&#8221; column_border_radius=&#8221;none&#8221; column_link_target=&#8221;_self&#8221; column_position=&#8221;default&#8221; gradient_direction=&#8221;left_to_right&#8221; overlay_strength=&#8221;0.3&#8243; width=&#8221;2\/3&#8243; tablet_width_inherit=&#8221;default&#8221; animation_type=&#8221;default&#8221; bg_image_animation=&#8221;none&#8221; border_type=&#8221;simple&#8221; column_border_width=&#8221;none&#8221; column_border_style=&#8221;solid&#8221;][vc_custom_heading text=&#8221;Drug Safety Reporting&#8221; use_theme_fonts=&#8221;yes&#8221; css=&#8221;&#8221;][vc_column_text css_animation=&#8221;none&#8221; css=&#8221;.vc_custom_1774535943591{margin-top: 15px !important;}&#8221; text_direction=&#8221;default&#8221;]At Cipla we take the safety of our patients and consumers very seriously. We know that side effects can happen but it is not always possible to predict who will get them. For this reason, it is vital for us to continuously monitor the safety of our products. By hearing about your experiences and others like you we are able to offer the best possible advice to those using Cipla\u2019s products.[\/vc_column_text][vc_row_inner column_margin=&#8221;default&#8221; column_direction=&#8221;default&#8221; column_direction_tablet=&#8221;default&#8221; column_direction_phone=&#8221;default&#8221; text_align=&#8221;left&#8221; row_position=&#8221;default&#8221; row_position_tablet=&#8221;inherit&#8221; row_position_phone=&#8221;inherit&#8221; overflow=&#8221;visible&#8221; pointer_events=&#8221;all&#8221;][vc_column_inner column_padding=&#8221;no-extra-padding&#8221; column_padding_tablet=&#8221;inherit&#8221; column_padding_phone=&#8221;inherit&#8221; column_padding_position=&#8221;all&#8221; flex_gap_desktop=&#8221;10px&#8221; column_element_direction_desktop=&#8221;default&#8221; column_element_spacing=&#8221;default&#8221; desktop_text_alignment=&#8221;default&#8221; tablet_text_alignment=&#8221;default&#8221; 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d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_3' style='display:none'><div id='gf_3' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_3' id='gform_3'  action='\/en\/wp-json\/wp\/v2\/pages\/772#gf_3' data-formid='3' novalidate> \r\n <input type=\"hidden\" class=\"gforms-pum\" value=\"{&quot;closepopup&quot;:false,&quot;closedelay&quot;:0,&quot;openpopup&quot;:false,&quot;openpopup_id&quot;:0}\" \/>\n        <div id='gf_progressbar_wrapper_3' class='gf_progressbar_wrapper' data-start-at-zero='1'>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>6<\/span><span class='gf_step_page_name'> - Reporter Details<\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_0' style='width:0%;'><span>0%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_3_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_70\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_70'>Instagram<\/label><div class='ginput_container'><input name='input_70' id='input_3_70' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_3_70'>This field is for validation purposes and should be left unchanged.<\/div><\/div><fieldset id=\"field_3_20\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Source<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_20'>\n\t\t\t<div class='gchoice gchoice_3_20_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Physician'  id='choice_3_20_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_20_0' id='label_3_20_0' class='gform-field-label gform-field-label--type-inline'>Physician<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_20_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Nurse'  id='choice_3_20_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_20_1' id='label_3_20_1' class='gform-field-label gform-field-label--type-inline'>Nurse<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_20_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Pharmacist'  id='choice_3_20_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_20_2' id='label_3_20_2' class='gform-field-label gform-field-label--type-inline'>Pharmacist<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_20_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Consumer'  id='choice_3_20_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_20_3' id='label_3_20_3' class='gform-field-label gform-field-label--type-inline'>Consumer<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_67\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_67'>Initials<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_67' id='input_3_67' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_68\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_68'>First name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_68' id='input_3_68' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_69\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_69'>Surname<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_69' id='input_3_69' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_2\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_3_2_container'>\n                                <span id='input_3_2_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_2' id='input_3_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_3_2' class='gform-field-label gform-field-label--type-sub '>Enter Email<\/label>\n                                <\/span>\n                                <span id='input_3_2_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_2_2' id='input_3_2_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_3_2_2' class='gform-field-label gform-field-label--type-sub '>Confirm Email<\/label>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/fieldset><div id=\"field_3_4\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_4'>Cellphone \/ Contact No.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_4' id='input_3_4' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_21\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_3_21' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_3_21_1_container' >\n                                        <input type='text' name='input_21.1' id='input_3_21_1' value=''    aria-required='false'    \/>\n                                        <label for='input_3_21_1' id='input_3_21_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_3_21_3_container' >\n                                    <input type='text' name='input_21.3' id='input_3_21_3' value=''    aria-required='false'    \/>\n                                    <label for='input_3_21_3' id='input_3_21_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_3_21_4_container' >\n                                        <input type='text' name='input_21.4' id='input_3_21_4' value=''      aria-required='false'    \/>\n                                        <label for='input_3_21_4' id='input_3_21_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_3_21_5_container' >\n                                    <input type='text' name='input_21.5' id='input_3_21_5' value=''    aria-required='false'    \/>\n                                    <label for='input_3_21_5' id='input_3_21_5_label' class='gform-field-label gform-field-label--type-sub '>Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_21.6' id='input_3_21_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_3_12\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_12'>Country<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_12' id='input_3_12' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select<\/option><option value='Kenya' >Kenya<\/option><option value='Tanzania' >Tanzania<\/option><option value='Uganda' >Uganda<\/option><option value='Ghana' >Ghana<\/option><option value='Madagascar' >Madagascar<\/option><option value='Mauritius' >Mauritius<\/option><option value='Zambia' >Zambia<\/option><option value='Ivory Coast' >Ivory Coast<\/option><option value='Nigeria' >Nigeria<\/option><\/select><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_3_16' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_2' class='gform_page' data-js='page-field-id-16' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_23\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_23'>Weight (kg)<\/label><div class='ginput_container ginput_container_number'><input name='input_23' id='input_3_23' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_3_24\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_24'>Height (cm)<\/label><div class='ginput_container ginput_container_number'><input name='input_24' id='input_3_24' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><fieldset id=\"field_3_25\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Date of birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div id='input_3_25' class='ginput_container ginput_complex gform-grid-row'>\n                                        <div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_3_25_2_container'>\n                                            <input type='number' maxlength='2' name='input_25[]' id='input_3_25_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_3_25_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_3_25_1_container'>\n                                        <input type='number' maxlength='2' name='input_25[]' id='input_3_25_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                        <label for='input_3_25_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                   <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_3_25_3_container'>\n                                        <input type='number' maxlength='4' name='input_25[]' id='input_3_25_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                        <label for='input_3_25_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                   <\/div>\n                                <\/div><\/fieldset><fieldset id=\"field_3_26\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Sex<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_26'>\n\t\t\t<div class='gchoice gchoice_3_26_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='Male'  id='choice_3_26_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_26_0' id='label_3_26_0' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_26_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='Female'  id='choice_3_26_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_26_1' id='label_3_26_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_33' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_3_33' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_3' class='gform_page' data-js='page-field-id-33' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_28\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_28'>Description of adverse event<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_28' id='input_3_28' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_3_29\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Event onset date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div id='input_3_29' class='ginput_container ginput_complex gform-grid-row'>\n                                        <div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_3_29_2_container'>\n                                            <input type='number' maxlength='2' name='input_29[]' id='input_3_29_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_3_29_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_3_29_1_container'>\n                                        <input type='number' maxlength='2' name='input_29[]' id='input_3_29_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                        <label for='input_3_29_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                   <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_3_29_3_container'>\n                                        <input type='number' maxlength='4' name='input_29[]' id='input_3_29_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                        <label for='input_3_29_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                   <\/div>\n                                <\/div><\/fieldset><fieldset id=\"field_3_30\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Event stop date<\/legend><div id='input_3_30' class='ginput_container ginput_complex gform-grid-row'>\n                                        <div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_3_30_2_container'>\n                                            <input type='number' maxlength='2' name='input_30[]' id='input_3_30_2' value=''   aria-required='false'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_3_30_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_3_30_1_container'>\n                                        <input type='number' maxlength='2' name='input_30[]' id='input_3_30_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                        <label for='input_3_30_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                   <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_3_30_3_container'>\n                                        <input type='number' maxlength='4' name='input_30[]' id='input_3_30_3' value=''   aria-required='false'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                        <label for='input_3_30_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                   <\/div>\n                                <\/div><\/fieldset><fieldset id=\"field_3_31\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Treatment received?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_31'>\n\t\t\t<div class='gchoice gchoice_3_31_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='Yes'  id='choice_3_31_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_31_0' id='label_3_31_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_31_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='No'  id='choice_3_31_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_31_1' id='label_3_31_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_32\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_32'>Specify treatment received<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_32' id='input_3_32' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_3_39\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Outcome of adverse event<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_39'>\n\t\t\t<div class='gchoice gchoice_3_39_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='Recovered'  id='choice_3_39_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_39_0' id='label_3_39_0' class='gform-field-label gform-field-label--type-inline'>Recovered<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_39_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='Recovered with sequelae'  id='choice_3_39_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_39_1' id='label_3_39_1' class='gform-field-label gform-field-label--type-inline'>Recovered with sequelae<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_39_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='Not recovered'  id='choice_3_39_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_39_2' id='label_3_39_2' class='gform-field-label gform-field-label--type-inline'>Not recovered<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_39_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='Unknown'  id='choice_3_39_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_39_3' id='label_3_39_3' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_40' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_3_40' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_4' class='gform_page' data-js='page-field-id-40' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_3_41\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Current or past relevant medical history<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_41'>\n\t\t\t<div class='gchoice gchoice_3_41_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='Yes'  id='choice_3_41_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_3_41\"   \/>\n\t\t\t\t\t<label for='choice_3_41_0' id='label_3_41_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_41_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='No'  id='choice_3_41_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_41_1' id='label_3_41_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_3_41'>Incl. concurrent illness, allergy, smoking, alcohol abuse<\/div><\/fieldset><div id=\"field_3_42\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_42'>Specify medical history<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_42' id='input_3_42' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_3_43\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_43'>Supply as a copy of medical file if up to date<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='1048576' \/><input name='input_43' id='input_3_43' type='file' class='large' aria-describedby=\"gfield_upload_rules_3_43\" onchange='javascript:gformValidateFileSize( this, 1048576 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_3_43'>Accepted file types: jpg, png, pdf, Max. file size: 1 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_3_43'><\/div> <\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_44' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_3_44' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_5' class='gform_page' data-js='page-field-id-44' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_48\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_48'>Suspect drug name and strength<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_3_48' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_49\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_49'>Dose and frequency<\/label><div class='ginput_container ginput_container_text'><input name='input_49' id='input_3_49' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_50\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_50'>Route<\/label><div class='ginput_container ginput_container_text'><input name='input_50' id='input_3_50' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_52\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Therapy start date<\/legend><div id='input_3_52' class='ginput_container ginput_complex gform-grid-row'>\n                                        <div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_3_52_2_container'>\n                                            <input type='number' maxlength='2' name='input_52[]' id='input_3_52_2' value=''   aria-required='false'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_3_52_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_3_52_1_container'>\n                                        <input type='number' maxlength='2' name='input_52[]' id='input_3_52_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                        <label for='input_3_52_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                   <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_3_52_3_container'>\n                                        <input type='number' maxlength='4' name='input_52[]' id='input_3_52_3' value=''   aria-required='false'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                        <label for='input_3_52_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                   <\/div>\n                                <\/div><\/fieldset><fieldset id=\"field_3_51\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Therapy stop date<\/legend><div id='input_3_51' class='ginput_container ginput_complex gform-grid-row'>\n                                        <div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_3_51_2_container'>\n                                            <input type='number' maxlength='2' name='input_51[]' id='input_3_51_2' value=''   aria-required='false'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_3_51_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_3_51_1_container'>\n                                        <input type='number' maxlength='2' name='input_51[]' id='input_3_51_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                        <label for='input_3_51_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                   <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_3_51_3_container'>\n                                        <input type='number' maxlength='4' name='input_51[]' id='input_3_51_3' value=''   aria-required='false'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                        <label for='input_3_51_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                   <\/div>\n                                <\/div><\/fieldset><div id=\"field_3_53\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_53'>Batch details<\/label><div class='ginput_container ginput_container_text'><input name='input_53' id='input_3_53' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_54\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_54'>Indication for use<\/label><div class='ginput_container ginput_container_text'><input name='input_54' id='input_3_54' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_56\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Action taken with suspect drug<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_56'>\n\t\t\t<div class='gchoice gchoice_3_56_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_56' type='radio' value='Continued unchanged'  id='choice_3_56_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_56_0' id='label_3_56_0' class='gform-field-label gform-field-label--type-inline'>Continued unchanged<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_56_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_56' type='radio' value='Continued, dose or dose regimen changed'  id='choice_3_56_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_56_1' id='label_3_56_1' class='gform-field-label gform-field-label--type-inline'>Continued, dose or dose regimen changed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_56_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_56' type='radio' value='Withdrawn'  id='choice_3_56_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_56_2' id='label_3_56_2' class='gform-field-label gform-field-label--type-inline'>Withdrawn<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_56_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_56' type='radio' value='Not applicable'  id='choice_3_56_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_56_3' id='label_3_56_3' class='gform-field-label gform-field-label--type-inline'>Not applicable<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_57\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_57'>Specify action taken<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_57' id='input_3_57' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_60\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_60'>Laboratory Tests &amp; Findings relevant to the adverse event<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='1048576' \/><input name='input_60' id='input_3_60' type='file' class='large' aria-describedby=\"gfield_upload_rules_3_60\" onchange='javascript:gformValidateFileSize( this, 1048576 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_3_60'>Accepted file types: jpg, png, pdf, Max. file size: 1 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_3_60'><\/div> <\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_59' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_3_59' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_6' class='gform_page' data-js='page-field-id-59' style='display:none;'>\n                    <div class='gform_page_fields'>\n              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class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_62_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='No'  id='choice_3_62_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_62_1' id='label_3_62_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_63\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_63'>Drug name and strength<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_63' id='input_3_63' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_66\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_66'>Optional attachment<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='1048576' \/><input name='input_66' id='input_3_66' type='file' class='large' aria-describedby=\"gfield_upload_rules_3_66\" onchange='javascript:gformValidateFileSize( this, 1048576 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_3_66'>Accepted file types: jpg, png, pdf, Max. file size: 1 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_3_66'><\/div> <\/div><\/div><fieldset id=\"field_3_65\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Consent to be contacted<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_65'>\n\t\t\t<div class='gchoice gchoice_3_65_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_65' type='radio' value='Yes'  id='choice_3_65_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_65_0' id='label_3_65_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_65_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_65' type='radio' value='No'  id='choice_3_65_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_65_1' id='label_3_65_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_64\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Privacy Policy<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_64.1' id='input_3_64_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_3_64\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_3_64_1' >I agree to the <a href=\"https:\/\/www.cipla.co.za\/wp-content\/uploads\/2021\/07\/Cipla-Website-Privacy-Policy.pdf\" target=\"_blank\">privacy policy<\/a>.<\/label><input type='hidden' name='input_64.2' value='I agree to the &lt;a href=&quot;https:\/\/www.cipla.co.za\/wp-content\/uploads\/2021\/07\/Cipla-Website-Privacy-Policy.pdf&quot; target=&quot;_blank&quot;&gt;privacy policy&lt;\/a&gt;.' class='gform_hidden' \/><input type='hidden' name='input_64.3' value='1' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_3_64' tabindex='0'>By submitting, you consent to Cipla South Africa processing your information and storing your contact details on our database.<\/div><\/fieldset><\/div><\/div>\n        <div class='gform-page-footer gform_page_footer top_label'><input type='submit' id='gform_previous_button_3' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='submit' id='gform_submit_button_3' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Send'  \/> <input type='hidden' name='gform_ajax' value='form_id=3&amp;title=&amp;description=&amp;tabindex=0&amp;theme=gravity-theme&amp;styles=[]&amp;hash=586690c934b0d0734633cf3a44d3bc89' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_3' value='iframe' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_3' id='gform_theme_3' value='gravity-theme' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' 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jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_3');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_3').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){form_content.find('form').css('opacity', 0);jQuery('#gform_wrapper_3').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_3').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_3').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/ jQuery(document).scrollTop(jQuery('#gform_wrapper_3').offset().top - mt); }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_3').val();gformInitSpinner( 3, 'https:\/\/ke.cipla.africa\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery(document).trigger('gform_page_loaded', [3, current_page]);window['gf_submitting_3'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}jQuery('#gform_wrapper_3').replaceWith(confirmation_content);jQuery(document).scrollTop(jQuery('#gf_3').offset().top - mt);jQuery(document).trigger('gform_confirmation_loaded', [3]);window['gf_submitting_3'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_3').text());}else{jQuery('#gform_3').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger(\"gform_pre_post_render\", [{ formId: \"3\", currentPage: \"current_page\", abort: function() { this.preventDefault(); } }]);        if (event && event.defaultPrevented) {                return;        }        const gformWrapperDiv = document.getElementById( \"gform_wrapper_3\" );        if ( gformWrapperDiv ) {            const visibilitySpan = document.createElement( \"span\" );            visibilitySpan.id = \"gform_visibility_test_3\";            gformWrapperDiv.insertAdjacentElement( \"afterend\", visibilitySpan );        }        const visibilityTestDiv = document.getElementById( \"gform_visibility_test_3\" );        let postRenderFired = false;        function triggerPostRender() {            if ( postRenderFired ) {                return;            }            postRenderFired = true;            gform.core.triggerPostRenderEvents( 3, current_page );            if ( visibilityTestDiv ) {                visibilityTestDiv.parentNode.removeChild( visibilityTestDiv );            }        }        function debounce( 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tablet_text_alignment=&#8221;default&#8221; phone_text_alignment=&#8221;default&#8221; background_color_opacity=&#8221;1&#8243; background_hover_color_opacity=&#8221;1&#8243; column_backdrop_filter=&#8221;none&#8221; column_shadow=&#8221;none&#8221; column_border_radius=&#8221;none&#8221; column_link_target=&#8221;_self&#8221; column_position=&#8221;default&#8221; gradient_direction=&#8221;left_to_right&#8221; overlay_strength=&#8221;0.3&#8243; width=&#8221;1\/3&#8243; tablet_width_inherit=&#8221;default&#8221; animation_type=&#8221;default&#8221; bg_image_animation=&#8221;none&#8221; border_type=&#8221;simple&#8221; column_border_width=&#8221;none&#8221; column_border_style=&#8221;solid&#8221;][vc_column_text css=&#8221;.vc_custom_1774606352187{margin-bottom: 10px !important;}&#8221; text_direction=&#8221;default&#8221;]\n<h4>Contact Drug Safety<\/h4>\n[\/vc_column_text][vc_column_text css=&#8221;&#8221; text_direction=&#8221;default&#8221;]<a href=\"mailto:drugsafety.ssa@cipla.com\">drugsafety.ssa@cipla.com<\/a>[\/vc_column_text][vc_column_text css=&#8221;.vc_custom_1594391004910{margin-bottom: 10px !important;}&#8221;]\n<h4>Location<\/h4>\n[\/vc_column_text][vc_column_text]Cipla Limited, Kenya<br \/>\nNivina Towers, 4th Floor,<br \/>\nMuseum Hill, Westlands Road,<br \/>\nNairobi, 46986 -00100, Kenya[\/vc_column_text][vc_column_text css=&#8221;.vc_custom_1594391034846{margin-bottom: 10px !important;}&#8221;]\n<h4>Contact Details<\/h4>\n[\/vc_column_text][vc_column_text]Kenya: 0207767055<br \/>\nHead Office: +27 21 943 4200<br \/>\nCustomer Care: 080 222 6662<br \/>\n<a href=\"mailto:info.kenya@cipla.com\">info.kenya@cipla.com<\/a>[\/vc_column_text][\/vc_column][\/vc_row]\n","protected":false},"excerpt":{"rendered":"<p>[vc_row type=&#8221;full_width_background&#8221; full_screen_row_position=&#8221;middle&#8221; column_margin=&#8221;60px&#8221; column_direction=&#8221;default&#8221; 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