1. Consumer details
Forname *
Surname *
Street and house number *
Town + postal code *
Phone or mobile number *
E-mail adress *
Date of birth: *
Gender * make a choice male female
Weight *
Pregnancy make a choice yes no
Months
2. Representative of the consumer details (if applicable)
Forname
Surname
Street and house number
Town + postal code
Phone or mobile number
E-mail adress
Relationship to client /patient make a choice Family member friend Physician Pharmacist Distributor other
Name of the product *
Name of the company that markets the product *
Product size *
Batch number *
Expiry date *
Date when the product was purchased *
Details from where this product was purchased * make a choice Pharmacy Health food store Internet Other
Name and address / website from where this product was purchased *
4. Complaints when taking the product
Date product was taken *
Which are you complaints *
What dose of the product have you taken? (how much at a time / how much per day)? *
Have you used this product before? * make your choice yes no
If so, for how long in the past have you used this product before
* Required fields to fill in
0 + 1 = ? Please prove that you are human by solving the equation *
