Adverse Event Form for HCP's

Please fill in the form below.

Adverse Event (HCP)

HCP Details

Name
Name
First
Last
Are you an AMET member?
If you are an existing AMET Member please enter your registered AMET email address. A copy of this completed form will be sent to the email address you provide.
What is your professional title?
Practitioner years of Aesthetic medicine experience

Adverse Event Details

Adverse Event Triage Category
Treatment Time
Treatment type (please tick all that apply)
What is the suspected or confirmed diagnosis? (Please tick all that may apply)
Please tick all clinical symptoms the patient is experiencing?
When did the clinical symptoms initially present?
Please select all treatment zones from below
Specific treatment area (please select all that apply)
Technique used

Patient Details

Maximum file size: 8MB

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