OneCall Adverse Event Reporting

Please fill in the form below to report any experience that is unexpected, unwanted or undesirable during use of any Baxter product.

Your Name:
E-mail address:
Address:
Phone:
Fax:
Organisation:
Which country did the event occur in:*:
Date you were first notified of the event*:
Date when the event occurred:*:
Your relationship to the patient *:
Product(s) name or code*:
Batch Number*:
Patient initials:*:
Patient age / age group:*:
Patient gender*:	Male Female Unknown
Description of adverse event*: