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Adverse Event Form
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Contact Details
Reporter/Consumer
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Your answer
Date
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MM
/
DD
/
YYYY
Reporter’s Name
*
Your answer
Reporter’s Address
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Your answer
Qualification
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Physician
Nurse
Pharmacist
Other Health Care Professional
Non-Health Care Professional
Other:
Telephone Number
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Your answer
Fax Number
Your answer
Email
*
Your answer
Country
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Your answer
Consent to contact reporter for additional information
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Yes
No
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