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Suspected Adverse Event Reporting Form

Suspected Adverse Event Reporting Form

In order to lodge a product reaction, it is a requirement that the information in this form is filled out in its entirety. This information is necessary for Therapeutic Goods Administration (TGA) reporting purposes, so we ask that you take the time to complete ALL sections of this form in order to proceed with the product return.

For quality and safety, we may need to inspect the product by organising a complimentary collection. Please ensure that the product is kept in a safe place until we confirm whether it needs to be collected or safely discarded.

"*" indicates required fields

PRACTITIONER INFORMATION

PATIENT INFORMATION

ADVERSE EVENT

DD slash MM slash YYYY
DD slash MM slash YYYY
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This field is hidden when viewing the form
DD slash MM slash YYYY
Were you taking any medications or vaccines at the time of the reaction?*
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This field is hidden when viewing the form
DD slash MM slash YYYY
DD slash MM slash YYYY
This field is hidden when viewing the form
This field is hidden when viewing the form
DD slash MM slash YYYY
DD slash MM slash YYYY
This field is hidden when viewing the form
This field is hidden when viewing the form
DD slash MM slash YYYY
DD slash MM slash YYYY

SERIOUSNESS OF EVENT.

Life threatening:*
Hospitalised:*
Required visit to doctor:*
Recovered:*
DD slash MM slash YYYY
Not yet recovered:*
Fatal:*
DD dash MM dash YYYY

ONGOING CONSEQUENCES

Select*

MEDICAL HISTORY

DD slash MM slash YYYY

Please note that we are collecting your personal information (including your health information) as part of our obligation to the Therapeutics Goods Administration to report any adverse reactions or product complaints and we will be sharing your personal information as well as the details of your experience with our product with the TGA. We may also use this information for our quality improvement purposes and to be able to contact you if required. If you have any questions on how we handle your personal information, please check our Privacy Policy available on Designs for Health Australia website. By filling out this form you consent to the collection of your information for these purposes.