This form is meant for members of the public and patients to report medicine side effects, adverse events following vaccination, incidents involving medical devices or poor quality medicinal products.
Health care professionals should register and submit reports after successfull authentication.

COA
DETAILS OF THE PERSON REPORTING

Your phone number is important for follow up by the
Pharmacy and Poisons Board and to obtain
additional information as well as providing you with the feedback

DETAILS OF THE PATIENT
clear!
-- clear!

If selected, year is mandatory.

--OR--
clear!
  
SIDE EFFECT
Select all side effects experienced
--
clear!
POOR QUALITY MEDICINE
Select all issues with the medicine/device
Additional wrong things?
DETAILS OF THE MEDICINE/VACCINE/DEVICE THAT CAUSED THE REACTION
(Include all medications)
1 Name of Medicine/Vaccine/Device Manufacturer
When did you start taking/using the medicine/vaccine/device? When did you stop taking/using the medicine/vaccine/device? (dd-mm-yyyy)
Expiry date of the medicine/vaccine/device Where did you buy the medicine/vaccine/device?
OUTCOME DETAILS

Outcome

clear!
Do you have pictures or documents that you would like to send to PPB? click on the button to add them:
# File Text Description
clear!
eight + four
=


Cancel