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  Fake Report ....  
Step 1 of 2: Reporter Details
Are you a member of the public, a healthcare professional, or other (non-healthcare/industry)? *
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Qualification
Title
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First name *
Surname
Organisation
House Name or Number
Address line 1
Address line 2
Country
City
Area
Postcode
Telephone Number
Email *
Password *
Step 2 of 2: Incident & Product Details
Incident details
Did the incident
     
Please describe the incident or problem, including any reactions if there were any
Product details
Product name and dosage *
Product licence number (from label starting with PL or EU). Enter none if not applicable *
Where and which country did you purchase the product from? *
Dosage form (tablet, capsule, cream, etc)
Please provide the name and address of the medicine's manufacturer, if known.
Is the packaging in English, or another language? Please state what language if known.
Has the medicine been prescribed by a qualified health professional, such as a GP or Nurse Prescriber?
Has the supplier been contacted? If so, what was their response? *
If the medicine is in tablet or capsule form, were they supplied to you without any packaging, or pre-packed in a blister pack only, or a blister pack and box?
Batch/lot number
Expiry date (from label)
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On what date did you buy the medicine?
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Open the calendar popup.
Is sample available for MHRA arranged testing?Is sample available for MHRA arranged testing? *
Please give details of any side effects experienced following consumption of the medicine.
 
Do you have any additional information you'd like to include?
You can email any further information relating to the suspected counterfeit product to [email protected].

Congratulations, you have registered successfully!