diff --git a/resources/views/form/rapport-dc/1775810563-29887e6c-dfe1-45cc-8dcd-2da516810bec.blade.php b/resources/views/form/rapport-dc/1775810563-29887e6c-dfe1-45cc-8dcd-2da516810bec.blade.php
index 86479449..df8c8b5d 100644
--- a/resources/views/form/rapport-dc/1775810563-29887e6c-dfe1-45cc-8dcd-2da516810bec.blade.php
+++ b/resources/views/form/rapport-dc/1775810563-29887e6c-dfe1-45cc-8dcd-2da516810bec.blade.php
@@ -274,18 +274,31 @@
 
         $('#report-form').on('submit', function(event){
             event.preventDefault();
+            var formulation = $('#field-glipiq_formulation').val();
             const rawDose = $('#field-glipiq_dose').val() || '';
             const doseSlug = rawDose.toString().toLowerCase().trim().replace(/[.\s]+/g, '_').replace(/[^a-z0-9_]/g, '');
-            
+            var inputName = '';
+
+            if (formulation === 'Vial') {
+                inputName = 'vial_' + slugDose;
+                inputValue = rxCount;
+            } else if (formulation === 'Pen') {
+                inputName = 'pen_' + slugDose;
+                inputValue = rxCount;
+            } else {
+                inputName = slugDose;
+                inputValue = '0';
+            }
+
             if($('#field-glipiq_formulation').val()==='Vial'){
-                $('#report-form').append('<input type="hidden" name="'+doseSlug+'" value="'+$("#field-count_of_rx").val()+'"  />');
+                $('#report-form').append('<input type="hidden" name="'+inputName+'" value="'+$("#field-count_of_rx").val()+'"  />');
             }
             else if($('#field-glipiq_formulation').val()==='Pen'){
-                $('#report-form').append('<input type="hidden" name="'+doseSlug+'" value="'+$("#field-count_of_rx").val()+'"  />');
+                $('#report-form').append('<input type="hidden" name="'+inputName+'" value="'+$("#field-count_of_rx").val()+'"  />');
 
             }
             else{
-                $('#report-form').append('<input type="hidden" name="'+doseSlug+'" value="0"  />');
+                $('#report-form').append('<input type="hidden" name="'+inputName+'" value="0"  />');
 
             }