Please complete the form in as much detail as possible so that information can be passed onto relevant supplier.  This form should only be used by products supplied by Alston Garrard & Co. Ltd.

Details of Person Submitting Form

Details of Drug
Suspected Drug Name:
Suspected Drug Strength:
Daily Dose:
Route of Administration:
Name of Manufacturer:
Product Batch Number:
Product Supplied From:

Details of Patient
Contact Telephone No:
Please complete one of
the following three options:
  • 1. Date of Birth:
  • 2. Age:
  • 3. Age Group:
Country Where Reaction Took Place:
Full Description of Reaction(s):
(Including outcome, relevant medical history and other medications taken)
Reaction Date:
Did Reactions Abate After Stopping Drug?
Additional Comments:
Form Submitted To:
Date of Form Submission: