ADVERSE EVENT REPORTING FORM
CONTACT DETAILS
Full Name
Telephone number
Email
Veterinarian or Animal Owner?
Veterinarian
Animal Owner
Clinic staff
Other
Please specify
Clinic name (if applicable)
Clinic Phone Number (if applicable)
State or Territory
ACT
NSW
NT
QLD
SA
TAS
VIC
WA
Other (Please add your location)
ANIMAL DETAILS OR HUMAN PATIENT
Name (if applicable)
Species
Breed (if applicable)
Sex/Gender
Reproductive status (if applicable)
Age
Weight
PRODUCT 1
Name (dose/strength-mg)
Batch number and expiry date (if available)
Date(s) administered
Has patient had product before?
Yes
No
PRODUCT 2 (if applicable – if more than 2 products please describe any additional in the Brief Description of the Event section below.)
Name
(dose/strength-mg)
Batch number and expiry date (if available)
Date(s) administered
Has patient had product before?
Yes
No
Has this been reported to APVMA?
Yes
No
Please provide a case reference number, if available
BRIEF DESCRIPTION OF THE EVENT
Adverse reaction, clinical signs/symptoms, duration, etc.
Upload relevant documents; clinical records/videos/photos
Would you like Zoetis to contact you to discuss this event further?
Yes
No
Preferred Contact Method
Phone Call
Email
Contact Information