Name *

First Name

Last Name

Phone *

(###)

###

####

Date of Birth *

MM

DD

YYYY

Expiration Date *

MM

DD

YYYY

Date of First Use *

MM

DD

YYYY

Date of Last Use *

MM

DD

YYYY

Date on Which Use of Product Was Reduced (if applicable)

MM

DD

YYYY

Date of Onset *

MM

DD

YYYY

Did the Event Abate After Stopping or Reducing Use? *

Yes

No

Doesn't apply

Did the Event Reappear after Reintroduction of the Product? *

Yes

No

Doesn't apply

Consent for Sharing the Information with Regulatory Authorities *

By submitting this form, I hereby give my consent for The Equity and Wellness Collaborative to collect, process, and use my personal data provided in this adverse event reporting form for the purpose of investigating the reported adverse event. I understand that my information may be shared with regulatory authorities as required by law but will otherwise be kept confidential and used solely for the purposes of addressing and investigating the reported issue. I acknowledge that The Equity and Wellness Collaborative is committed to protecting my privacy and ensuring the security of my personal data in accordance with United States data protection laws.

Yes

Statement Confirming the Accuracy of the Information Provided to the Best of the Reporter's Knowledge *

I declare that, to the best of my knowledge, the information provided in this report is accurate and complete. I understand the importance of reporting accurate and detailed information to ensure the effective investigation of the reported adverse event. I agree to be contacted by The Equity and Wellness Collaborative for further information if necessary to assist in the investigation of this report.

Yes