AE Form for HCPs – Aesthetic MET

患者詳細

イニシャルのみ

患者の年齢／生年月日

現在服用している薬（処方箋またはその他）

アレルギー（薬またはその他）と反応の種類。

病歴（手術、歯科治療、予防接種、その他の治療を含む）

患者の同意を得た写真

最大ファイルサイズ：1.54MB

ファイルのアップロード

最大ファイルサイズ：1.54MB

トリアージ／フィールド・エキスパートのコメント

*The AMET nurse team will be notified via text message once this form is completed. We will respond via email within 24 hours; if in need of urgent assistance, contact AMA. AMET nurse email support service operates between AEST 8am-8pm Monday to Friday and 9am-5pm Saturday and Sunday.   If your request comes through outside business hours we will do our best to respond as soon as possible or within the next operating business hours. Please refer to adverse event protocols in the members only section on the AMET site able to be accessed 24/7. Please do not delay care to your patient and these times are a guide. 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.

あなたが人間の場合、このフィールドは空白のままにしてください。

HCP用有害事象フォーム

医療従事者の詳細

有害事象の詳細

患者詳細