For Benefit medicines
PO Box 45
27 Kirrawee Rd
North Gosford NSW
Ph: 1300 656 256
Fax: (02) 9475 1031
Monday – Friday: 9AM – 5PM
You may report an adverse event related to an FBM product in two ways:
1. Print out and complete this form and fax it to (02) 9475 1031
2. Electronically by sending an email to firstname.lastname@example.org
When submitting in an e-mail format please provide the following information in your email:
- Name of the drug:
Description of when the patient started the medication, including dosing strength and frequency (amount and how often, e.g. 1mg once daily). Any action taken with the medication (e.g. reduced dose, stopped) and impact of that action on the side effect.
- The side effect associated with the drug:
Symptom evolution over time. Description of any treatment needed for the side effect. Name of healthcare provider who provided treatment and contact information.
- Your name (optional):
Please note that your personal identifying information (e.g. name, email address) will not be shared with the health authorities. FBM or its agents may contact you for further information about the side effect. If you do not wish to be contacted, you should indicate this in your email.
- Information about the person who experienced the side effect:
Any other medical conditions currently ongoing. Medications currently taken (name, dosing strength, frequency, and when medication was started). Gender and age of the person taking medication (optional).
The personal information that you provide will be used for the purpose of contacting you in relation to your questions, suggestions and comments. You have the right to access your information by contacting our Privacy Officer at: email@example.com.