AE Form for HCPs – AestheticMET AU/NZ

Patient Details

INITALS ONLY

Patient age / date of birth:

Current Medication (prescription or other)

Allergies (medicines or other) and reaction type.

Medical history (including surgery, dental, vaccinations or any other medical treatment)

Photos with patient consent

Maximum file size: 8MB

File Upload

Maximum file size: 8.39MB

Triage/Field Expert Comments

This form is messaged immediatley to the triage team to call back the health care professional. Please note the triage support is provided as general medical information. Completing this form is the quickest way for our team to call you back.  AMET needs the contact information you provide  to contact you about the reported adverse event.  You may unsubscribe from these communications at anytime. For information on how to unsubscribe, as well as our privacy practices and commitment to protecting your privacy, check out our Privacy Policy. Please note reporting the adverse event does not replace reporting to  TGA, pharmaceutical companies or any legal obligation as a health care practitioner. Please do not delay care for your patient by completeing this form.  Reporting of an adverse event is only to be captured by the treating HCP and / or prescribing practitioner whom has treated and or presribed the medicine to the patient experiencing the adverse event or is actively managing the adverse event. By reporting the adverse event you are consenting and confirming the patient has given consent to report,  upload file and images of the adverse event to AMET  and AMET will only use for support, complication management and internal educational purposes. If you have an active adverse event please manage as per your protocols and if you require assistance please contact AMET via this online form.

If you are human, leave this field blank.

Adverse Event Form for HCP's

Healthcare professional details

Adverse Event Details

Patient Details