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First Name *

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Telephone number *

Country *

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Patient

Who experienced the suspected side effect? *

Patient Gender *

Patient age at the time of side effect *

Patient Weight (kg) *

Patient Weight (stones) *

Patient Weight (pounds) *

Country of Residence *

Product

Brand of Product *

Name of Product *

Start Date *

End Date

Product Type *

Batch Number

Action taken with product as a result of the reaction *

Product Source

Where did you obtain the product *

Name of Retailer *

Country *

Address line 1 *

Address line 2

City *

Postcode *

Side Effects

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Summary

Declarant

Patient

Product

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Side Effects

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Declarant

Patient

Product

Product Source

Side Effects

Summary

Declarant

Patient

Product

Product Source

Side Effects