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Natural Medicines Watch: Adverse Event Reporting Form

To report an adverse event or side effect related to a natural medicine, complete the form below. Your report will improve healthcare by aiding researchers and will be forwarded to the appropriate regulatory agency…such as the Food and Drug Administration.
1.  Your name:
2.  Your profession:
Do you represent a product manufacturer?  
Are you a health professional?  
3.  Your contact information:

Your
Info
4.  Patient Information if known: Patient
Info
To protect privacy, do NOT enter patient names or any other patient identifiers. A tracking number will be issued upon completion of this report that you can use for the patient's records, if necessary.
Did you personally experience this adverse event or side affect?  
Gender:   
  years 
Race/Ethnicity:





 
  *   *      *
Does this report pertain to military personnel?
5.  Product(s) suspected to have caused adverse event or side effect:
Add suspected products
6. 
Search for medications, select from a list, or enter the completed drug name below:
7. 
Search for conditions, select from a list, or enter the full condition name below:
8. 


Medicines & Conditions
9.  Adverse Event Details Adverse Event
Info
Check all outcomes that apply to this adverse event:    ( 
 
 
 
 
 
 
    
10. 
11. 
Did the symptoms resolve when the product was discontinued?        

12. 
If the product was taken again, did the adverse event occur a second time?        

13. 
Confidentiality and Privacy Notice: No information will be collected or stored unless the person providing the information agrees. Natural Medicines Watch will never use information provided for any marketing purpose whatsoever. No information will be shared with any other person or party unless the person providing the information agrees. Persons submitting a report about a patient or another person are encouraged not to provide the patient’s name or any information that would identify the patient. Data will be analyzed to identify potential safety issues and trends. Analysis of this data is only conducted in a patient and reporter de-identified manner. The reporter’s identity is collected in the event that additional follow-up is needed. Information collected from this form will be forwarded to regulatory bodies, such as the Food and Drug Administration, and may be shared with product manufacturers and research organizations. If you have any questions or concerns about this, please email privacyofficer@naturalmedicineswatch.com or call, 209-472-2244.
Additional Privacy Options
It is OK for Natural Medicines Watch staff to follow-up with me if needed.  
It is OK to disclose my name to regulatory bodies, researchers, or product manufacturers.  
 
Required