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Suspected defect online form

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Suspected defect online form

Report made by


Name*
Organisation*
Position / Status
Address*
Postcode*

Telephone (* at least one number required)


Work direct dial:
Work switchboard:
Mobile:

Email address
Confirm email address

Alternate email address
Confirm alternate email address

Product details


Product name*
Supplier Name (from label)*
Manufacturing site
Product licence Number (from label)*
Legal Status
Dosage form* E.g tablet, capsule, cream etc.
Strength (from label)*
Container type / size
Batch / Lot number*
Expiry date (from label)*
Date first distributed (if known)
Is sample available for MHRA arranged testing?

Defect


Please give details of the reported defect and details of any associated clinical incident*