Food and drugs authority forms

CONSUMER REPORTING FORM

We are sorry that you or someone that you know has had a reaction to the medicine they were taking or vaccine given. Information you provide when you report side effect can improve the safe use of medicines or vaccines. Please provide your contact details below so we can follow up for further information about your report if necessary. You can report on side effects, drug ineffectiveness, product quality, suspected counterfeit or medical device defect, medication error (i.e. mistake made in the prescription, dosing, dispensing or administration of the medicine).
Please note: all fields marked (*) red are required.

* First Name * Second Name Town / City * Name or Initials * Age at time of the side effect * What were the signs of the side effect? * When did the side effect start? When did the side effect stop? Please select if the side effect resulted in any of the following: Please Specify

Do you think these side effect occurred as a
result of a mistake made in the prescription, dosing,
dispensing or administration of the medicine or vaccine?

* Suspected Medicine / Vaccine Batch Number Manufacturer Expiry Date Date drug was started Date you stopped taking the drug What form did you take your medicine/ vaccine
given to you? What was/were the reason(s) for taking the
suspected medicine? (Indication) Where was medicine obtained or vaccine given ? What action was taken with this medicine
as a result of the side effect(s) Name of Medicine Date Started Date Ended Reasons for use

Other information you think might be important,
including any other medical condition,
any allergies that the person may have,
results of any tests performed etc.

If we need further information to help us
understand the case do we have your
permission to contact you?