Declarant

Email *

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

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

Add Side Effect

Remove Side Effect

Summary

Declarant

Patient

Product

Product Source

Side Effects

Send copy to my email

I agree with privacy policy *

DotMod

Welcome to the DotMod, Inc. safety concerns portal.

Please use this form to report a suspected side effect or safety concern for one of our products.

Thank you.

DotMod, Inc.

Declarant

Patient

Product

Product Source

Side Effects

Summary

Declarant

Patient

Product

Product Source

Side Effects