Product or Quality issue Form
Are you a healthcare professional?:*
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Job title:*
Company name:*
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)*

Reporter Details:

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Product Information

Product name:*
Product description:
Batch number / Serial number:.*
Tablet/Capsule marking (Imprint):
Product expiry date:*
Product quantity:
Place of purchase:
Is the product available for return?:

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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