Patient adverse reaction register

Adverse reaction register

This form can be used by practitioners and patients to record an adverse reaction to a Spectrumceuticals supplement. This report will be emailed to as PDF document in the case of a serious adverse reaction. For mild and moderate reactions we hold on record for the Therapeutic Goods Administration (TGA) audits. Information is NOT stored on this website. Any issues completing the form call us on 1300 852 775 or Live Chat us on this website.

Patient Details

Are you a healthcare practitioner completing on behalf of a patient or are you a patient?(Required)
First and Last name (if you are a patient, this is your practitioners name).
First name of the patient.
Initials of the patient.
Phone number of the person completing this form. Otherwise we will use email to follow up.
Required for follow up. Email of the person completing this form.
Patient. TGA requirement
Patient. TGA requirement

Adverse Reaction Details

DD slash MM slash YYYY
DD slash MM slash YYYY
Yes we will refund all adverse reactions including mild for purchases made directly from us. Yes we do credit pharmacies and healthcare practitioners for your reported reaction, so you should be refunded from where you purchased the product.
Please enter a number greater than or equal to 1.
Please enter the total daily dose you are taking
TGA requirement
TGA requirement
Current medications
Please add current medications so we can review possible contraindication, Click the ‘+’ or ‘-‘ signs on the end of each row to add or delete lines.
Have you contacted your prescribing healthcare practitioner?(Required)
If you are experiencing a suspected adverse reaction please seek immediate medical assistance.
Severity of reaction(Required)
TGA requirement
TGA requirement