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(Kindly fill in the relevant information or tick, as appropriate.)

Patient ID*

Age(in Years) *

Weight (in Kg)*

Gender *

Male Female

Treatment Duration (Days)*

Sporidex CV (375+125) $ Sporidex CV (750+125) $

($: Cephalexin and clavulanic acid respectively)

Adverse Event *

Yes No

1. Description*

According to you, what qualities in sporidex CV makes it prescription of your choice*