Adverse Reaction/Incident Form

Product/Treatment Identification
Please select the product used and/or treatment performed: *
Batch Number *
Example: B15G789 - the batch is located on the back of the bottle or on the crimp of the tube. For treatments please write N/A
Qty (1)
Reason for return (1)
Please select the second product used
Batch Number
Qty (2)
Reason for return (2)
Please select the third product used
Batch Number
Qty (3)
Reason for return (3)
Please select the fourth product used
Batch Number
Qty (4)
Reason for return (4)
Please select the fifth product used
Batch Number
Qty (5)
Reason for return (5)
Please select the sixth product used
Batch Number
Qty (6)
Reason for return (6)

Client identification

the person who experienced the adverse reaction
Gender *

Male Female unknown
Age
Full Name

First Name Last Name
Contact details - Phone
Contact details - E-mail
Do we have the person's consent to disclose details of affected person (to relevant regulatory & government authorities eg ACCC, TGA, Department of Health & Human Services, NSW Fair Trading, etc)? *

Yes No
Please provide your name and details *
The person who completed the form
Should be Empty:

Product/Treatment Identification