SECTION 1 | Veterinarian detailsName(Required) Dr.MissMr.Mrs.Ms.Mx.Prof.Rev.SirCol.Hon.LadyOther Prefix First Last Veterinary registration(Required)Please add a new line if registered with more than one state.StateRegistration number Add RemovePractice namePractice address Street Address Address Line 2 City Australian Capital TerritoryNew South WalesNorthern TerritoryQueenslandSouth AustraliaTasmaniaVictoriaWestern Australia State Postcode PhoneAlternate phoneEmail Do you give permission for your contact details to be forwarded to the product manufacturer where possible?(Required) Yes No SECTION 2 | Patient detailsWhat is the suspected diagnosis (or diagnoses)?Species Cat Dog BreedPatient nameAge of patientAge in years, months or weeks:-- Select an option --YearsMonthsWeeksSex of patient M NM F NF Bodyweight (kg)Date of examination(s)Please add a new line for additional examination dates. Add RemoveMain problems reported by ownerClinical signs identified by veterinarianSECTION 3 | Suspected food product(s)Have you contacted the product manufacturer?(Required) Yes No Details of discussion with the manufacturer:(Required)Diet historySuspect pet food sourceHow many suspect food products are you reporting?(Required)123Brand and product name(Required)Pack type and weightPlace of purchaseManufacturerAs shown on product label.Date on pack DD slash MM slash YYYY Date labelling Use by Best before Packaging date Batch or other identification code on packBrand and product name #2(Required)Pack type and weightPlace of purchaseManufacturerAs shown on product label.Date on pack DD slash MM slash YYYY Date labelling Use by Best before Packaging date Batch or other identification code on packBrand and product name #3(Required)Pack type and weightPlace of purchaseManufacturerAs shown on product label.Date on pack DD slash MM slash YYYY Date labelling Use by Best before Packaging date Batch or other identification code on packCAPTCHA
