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Adverse Event Reporting
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Patient Name
*
First
Last
Date of Birth
Phone
Address
Address Line 1
Address Line 2
City
— Select state —
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Email
*
What is your preferred contact method?
Phone
Email
When is the best time to contact you?
Morning
Afternoon
Evening
Prescription Number
Compound Name
Did it pertain to a dispensing device?
Yes
No
Did it happen more than once?
Yes
No
Did you contact your primary care provider?
Yes
No
Practitioner Name
*
First
Last
Practitioner Phone
Did you receive any medical care for the issue with the compounded medication?
Yes
No
Submit