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Medical Information Enquiry

To submit a Medical Information enquiry, kindly complete the form provided below. Our Medical Information team will get back to you as soon as possible. Please note that this request form is intended for healthcare professionals (HCPs), but patients/individuals can submit a request. Responses for HCPs will be handled in line with the regulations of engagement with HCPs that are specific to your country. If you have an urgent question, please reach out to Medsurge Healthcare directly.

Please note that this form is not to be used to report adverse events or product quality complaints. Please report adverse events here (go.medsurgehc.com/au-adverse-event-form) or product quality complaints here (go.medsurgehc.com/au-quality-form).



Are you a healthcare professional?*
First name:*
Last name:*
Company name:*
Email address:*
Business phone (inc country code and area code, i.e. +61300000000):*
Business mobile (inc country code and area code, i.e. +61300000000):
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)*

Please provide information about the product.

Medsurge product code: (If know)
Drug/Product name:*

Reporting Patient/Individual:

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

Address:

Street:
City:
State:
Country:
Zip / Postal code:

Patient Identifier (Patient initials only):

Patient first name initial:*
Patient last name initial:*
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):


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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