Declarant

E-mail *

Title *

First Name *

Surname *

Telephone number *

Country *

Address line 1 *

Address line 2

City *

Postcode *

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 (if known)

Action taken as a result of the reaction to the product *

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

Product Source

Side Effects

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Declarant

Patient

Product

Product Source

Side Effects

Summary

Declarant

Patient

Product

Product Source

Side Effects