Your name —Please choose an option—jamie.corbett@tankww.comstephanie.granowicz@tankww.comLea Monaco lmonaco@tank.ca
Is this a new submission: NewFollow-up
If this is a follow-up, please enter original file number
What date was this report posted
What time was this report posted (HH:MM 24 hour format)
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Submitter’s name
What is the Gender of the patient: UnknownMaleFemaleBoth
Full product description
Product Indication
Reporter ConsumerDoctorNursePharmacistOther
What country does the reporter live in:
Did the reporter consider the event was possibly related to the product use: UnknownYesNo
If provided, please enter Patient HCP contact details bellow, if available: NA
Information about the patient (person) or groups who used the product, if available: NA
Was this an individual or multiple users IndividualMultipleUnknown
What was the age of the user
Was the patient pregnant when using the product UnknownYesNo
Other Comment? None.