Adverse Event Reporting

Our ultimate goal is to provide everyone with safe and effective products. If you experience any adverse reactions to any of our medicines, we encourage you to first speak with a healthcare professional before reporting it to us. Doing so helps us to efficiently monitor the safety of our medicines.

Medsurge does not provide medical, healthcare, or counselling services. If you require assistance with your health or medical treatment, including any Medsurge products, please consult with your physician or healthcare professional.

Are you a healthcare professional?:*
First name:*
Last name:*
Account/Company name:*
Job title:
Email address:*
Business phone:*
Business mobile:
Full legal entity name:*
What's your healthcare/business role or function*
HCP licence number:*
Licensed country:*
Licensed state:*
Licensed suburb:*
Licensed post code:*
What's your specialty area (if applicable otherwise select: no specialty)*

Reporting Patient/Individual:

First name:
Last name:
Job title:
Organisation name (If Applicable):
Email address:*

Patient Identifier (Patient initials only):

Patient first name initial:*
Patient last name initital:*
Patient DOB:
Patient age:
Patient gender:
Patient body weight (Kg):
Indigenous status:
What is the persons ethnicity?:
Was the person pregnant at the time (If applicable):

Suspected drug(s):

Medsurge product code: (If know)
Drug/Product name: *
Batch-no. or Serial-no: If unknow, please write unknown.*
Expiry date:*
Place of purchase: (If unknown, please write unknown.)*
Please include commencement date, trade name, dose and routine of administration:
Current medications: (Please list all current medications)

Adverse event details:

Onset date of reaction:
Patient symptoms:
Severity of symptoms:
Treatments (if applicable):
Other relevant information:
Observations (weight, height etc):

Acknowledgement of disclaimers/terms

Legal Disclaimer

We are legally obliged to collect adverse event reports and, where appropriate, report them to the health authorities. For this purpose, patient personal data that could be used for identification, will be added as an alias or anonymised according to legal requirements when entered into our adverse event database.

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