Adverse event report regarding a product

This form is only to be used for product related injury or illness.

Details of person making report

Name

Phone

Address Line 1

Address Line 2

City

State

Post Code

Country

Are you a medical practitioner?

Yes No

Purchaser Details

Same as above

Product Details

Product Name

Batch numberPrinted on product container

Purchase Date

Place of Purchase

Country of Purchase

I have receipt or proof of purchase

Yes No

Note: We will ask for a copy of receipt later to validate your report.

Injured Person Details

Same as person making this report

Date of birth

Date of injury or illness

Has, or will, the injured person receive any form of medical treatment?Note: Medical treatment includes treatment provided by or under the supervision of a medical practitioner or nurse.

Yes No

How did the product cause the injury? Provide details of injury and when injury first started. Consider: how were you using the product when the incident occurred, what are/were your symptoms, when were you using the product, how soon after using the product did the symptoms develop, etc. Note: we will require a medical report or records later.

Privacy

1. Hismile might be required to report this incident to external parties. By submitting this form, you acknowledge that we may be required to disclose the above information, including personal identifiable information, to external parties. Our privacy policy will apply.

2. By submitting this form, you acknowledge we may contact the reporter/purchaser/injured person again if we need additional information.