Report adverse event

Adverse event report regarding a product

This form is only to be used for product related injury or illness to persons. Do not submit this form for order tracking or updates.

Details of person making report

Are you a medical practitioner?

Yes No

${errors.medical_practitioner}

Purchaser Details

Same as above

Product Details

Product Name ${errors.product_name}

Batch number ${errors.product_batch} Printed on product container

Purchase Date ${errors.purchase_date}

Place of Purchase ${errors.purchase_location}

Order number ${errors.order_number} e.g. ${order_number_example}

Country of Purchase ${errors.purchase_country}

I have receipt or proof of purchase

Yes No

${errors.has_receipt} Note: We will ask for a copy of receipt later to validate your report.

Injured Person Details

Same as person making this report Same as purchaser

Date of birth ${errors.birth_date}

Date of injury or illness ${errors.injury_date}

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

${errors.treatment_received}

Type of Medical Treatment

Doctor

Dentist

Nurse or paramedic

Other - please provide details

Please provide details

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. ${errors.injury_details}

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. ${errors.notice_part_1}

2. By submitting this form, you acknowledge we may contact the reporter/purchaser/injured person again if we need additional information. ${errors.notice_part_2}

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