Reporting form for suspected adverse reactions to medicines / complementary products / medical devices

If you suspect an adverse event, please complete this form. Do not put off reporting because some details are not known. Submission of a report does not constitute an admission that medical personnel or the product caused or contributed to the adverse reaction. Identity of the patient and or / the reporter is kept strictly confidential.

Patient Information

Suspected Medicine

Other medicines taken at time of reaction with therapy dates
(exclude treatment of event)

Details of adverse reaction

Reporting Doctor / Pharmacist / Nurse / Dentist / Other

Thank you! Your submission has been received!
Oops! Something went wrong while submitting the form.