Adverse Events
Are You a Healthcare Professional?:*
First Name:*
Last Name:*
Account/Company Name:*
Job Title:
Email Address:*
Business Phone:*
Business Mobile:
Healthcare Role or Business Function:

Reporting Patient/Individual (Non-Healthcare Professional):

Reporter Type:
First Name:*
Last Name:*
Job Title:
Organisation Name (If Applicable):
Email Address:*


Zip / Postal Code:

Patient Identifier (Patient initials only):

Patient First Name:*
Patient Last Name:*
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):

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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.