MedWatch Voluntary Report

Relevant Tests/Laboratory Data:

Test Date (mm/dd/yyyy):

Test Name:

Test Result:

Test Unit:

Low Test Range:

High Test Range:

+ Add Another Test (You may add up to 8 rows)

Additional Comments:

Please select the cause of the problem that applies below:

For a problem with a product, including:

prescription or over-the-counter medicine
biologics, such as blood transfusions, gene therapies, and human cells and tissues transplant (for example: tendons, bone and corneas)
nutrition products, such as vitamins and minerals, herbal remedies, infant formulas, and medical foods
cosmetics or make-up products
foods (including beverages and ingredients added to foods)

For a problem with a medical device, including:

any health-related test, tool, or piece of equipment
health-related kits, such as glucose monitoring kits or blood pressure cuffs
implants, such as breast implants, pacemakers, or catheters
other consumer health products, such as contact lenses, hearing aids, and breast pumps

Do you still have the product in case we need to evaluate it?
(Do not send the product to FDA. We will contact you directly if we need it.)

Yes

Do you have a picture of the product? (check yes if you are including a picture) Yes

U.S. Food and Drug Administration