Product Complaint

Select Complaint Type Below Before Proceeding

Complaint Source

Complaint Type *

Reporter Information

First Name *

Last Name *

Title ?

Place of Work *

Phone *

Work Address

Email *

Preferred Contact Method

Suspect Product Information

Product Name/Description *

Product Code

Lot/Batch Number

Expiry Date

Number of Identical Events from Same Batch/Lot

Remaining Quantity from Same Lot/Batch

Patient Information

Patient Initials

Sex

Age at Time of Event

Weight

Complaint/Event Details

Event Occurred

Date of Event *

Complaint/Event Description * ?

Name of Attending Physician *

Severity of Reaction

Related Reaction Outcome

TRANSMED Rep notified? *

Additional Information

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