Dansys

Report Form for Product Complaints and suspected Adverse Effects / Reactions

Please fill out the below report form in case of product complaints or adverse product effects

*Required fields

Reporter Name *

Customer Name *

Customer Contact Number *

Customer Email *

Customer Address

Product Type *

Product Name *

Product Serial No. *

Date of Occurrence

Description of the Complaint *

Another product used previously/before?*

If yes, which product? *

Patient Gender *

Patient Age

Patient Weight

Patient Height

Reason for use

Route of application

Further persons affected?

If yes, how many?

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Dansys