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Adverse Event Reporting

If You Are Experiencing an Adverse Event,
Please Fill Out the Form Below

Patient Name(Required)
MM slash DD slash YYYY
Address
Preferred Method of Contact
When is the Best time to Contact You?
Did it Pertain to a Dispensing Device?
Did it Happen More Than Once?
Did You Contact Your Primary Care Provider?
Practitioner Name
Did You Receive Any Medical Care for the Issue With the Compounded Medication?