Report Side Effects

Date of Report

Time Reported

Name

Phone Number

Additional Contact Details

Details of Complaint (please include nature of reaction as well as when it started/stopped)

Product Name & Strength

Max No:

Batch No:

Expiry Date:

I would like acknowledgement of this report and an outcome once investigated / reviewed: YesNo

I consent to the processing of my data in line with the company privacy and data processing policy: YesNo

All reports are treated confidentially. If you selected "No" for consent, the report will still be recorded but handled according to policy.