1. Reporter Details

You are completing this report as a Member of the public

We are sorry to hear that you or someone that you know has had a side effect to the medicine they were taking. The information that you provide when you report the experience to us can help us in our work to identify previously unrecognised side effects, and thereby improve the safe use of medicines.

We would appreciate if you could please provide your contact details below so we can follow up for further information about your report if necessary.

Fields that you must complete are marked with this symbol: Required

Contact Method

Contact Method

Please provide a postal address, email address or both.

Address

Address

Telephone Number

Telephone Number

Privacy Policy

Privacy Policy

Form actions Step 1. Reporter Details