Adverse Reaction Enquiry Form for Healthcare Professionals

Name
Your Position / Profession
Contact Number(s)
Email Address
Address
How would you prefer that we contact you?	PhoneEmailPost
When would you like us to respond by? (If your enquiry is clinically urgent please contact us direct)	< 7 days 1 - 2 Weeks > 2 weeks

Please give the details of your enquiry below. It helps us if you give us as much background information as possible and then ask a specific question.

If your enquiry does not regard a particular patient please leave this section blank.

Age Weight (kg) 

Sex  M M

Any renal, hepatic or other impairment or other concurrent medical conditions of relevance? (Please give lab values where relevant)

Please include doses, indications and start dates where known.

Please indicate which resources you have already checked and what you have found so that we don't duplicate your efforts.