First Name
*
Last Name
*
Email address
*
Verify Email address
*
Customer Number
Street Address
*
Additional Street Address
City
*
Country
*
Postal Code
*
Phone Number (including International Dialing Code)
*
Reason for Contact
*
Choose One...*
Undesired Product Effect
Product Quality Issue
Product Query
Data Subject Access Request
Message
*
Age at the time of Reaction
Sex
Choose One...
Male
Female
Unknown
Suspect Products
Product Start Date
List date event started or occurred
Date stopped using product
Did problem stop after discontinuation?
Choose One...
Went Away
Decreased/Lessened
Remained_the_same
Increased/Worsened
How often have you used the product?
Choose One...
Used once
Daily
2 or more times a day
Weekly
2 or more times a week
Monthly
2 or more times a month
What are the events experienced in chronological order (consumer experience)?
Did you seek medical attention?
Choose One...
Yes
No
Medical Treatment Received and/or Prescribed (Please include lab test and/or results)
Do you have any pre-existing medical conditions?
Choose One...
Yes
No
Are you currently taking any medications?
Choose One...
Yes
No
Do you have any allergies?
Choose One...
Yes
No
Complaint Description (what happened and how it happened)
Actions Taken by Complainant
Date Complaint Occurred / Discovered
Product Kit Name
Kit/Product Code
Product(s) Available? (for evaluation)
Choose One...
Yes
No
Who the report is for?
Choose One...
My patient
Myself
My child
No
Consent for follow up with doctor
Choose One...
Yes
No
Submit