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Adverse Event and Product Quality Reporting

If you suspect an adverse event either in animals or humans may be associated with the use of an MSD Animal Health product and/or you suspect a product quality issue with an MSD product or device please report the details immediately using the form below.

For further advice about a case please call 01908 685685.

Fields marked with * are mandatory, ** only one field is mandatory

Your details

Your full name: *

Title: *

Dr

Mr

Mrs

Ms

Other

Title: Other

Your role: *

Your role: Other (please specify)

For emergency advice, please call 01908 685685

Preferred Contact Details:

Phone: *

Preferred time for call:

Email: *

Address:

Are you contacting us about (please select all that apply):

Are you contacting us about (please select all that apply)

An adverse event or lack of efficacy in an animal(s) relating to the use of an MSD Animal Health product?

An adverse event in a human(s) relating to the use of an MSD Animal Health product?

A suspected fault with an MSD Animal Health product or device?

A concern relating to off label use or medication error of an MSD Animal Health product?

Animal details

Please submit one form for each individual patient.

Species: *

Species: Other (please specify)

Breed (if applicable):

Animal name or ID number: *

Owner surname or ID number: *

Animal’s Age: *

Sex: *

M

MN

F

FN

Multiple animals

Weight (if known):

Clinical status of animal at time of administration including details of any concurrent conditions: *

Human details

Is this about yourself?

Yes

No

If this is about someone else, do we have permission to collect their details?

Yes

No

Full Name:

Phone number:

Email:

Address:

Do we have permission to contact them? *

Yes

No

Preferred contact details of affected person(s) and time for callback:

Other information:

Practice details

Practice/Company name: *

Address: *

Postcode: *

Practice telephone number: *

Name of attending vet:

Product details

Animal name or ID number:

Owner surname or ID number:

Date dispensed:

Product name: *

Date(s) administered (where applicable):

Batch numbers (if known):

Formulation (e.g. tablets/liquid/injection): *

Strength (if known/where relevant):

Product/Bottle size *

How many products are affected? *

Did the packaging appear damaged or tampered with?

Yes

No

Temperature of product at time of administration (if known):

List any other products used concurrently:

Where applicable, give details of route, site and dose for each product administered:

Distribution partner:

MWI

NVS

Distribution partner account number:

Is the product available for return if required?

Yes

No

Please provide full details of the clinical concern for this report including date re-presented and relevant clinical symptoms seen where applicable:(please do not provide an attached history as this will be requested if required.) *

Was any treatment required and the noted response suspected adverse event or lack of efficacy: *

Please include any laboratory reports if available via attachment option on this form: *

Current status of case – resolved/ on-going reporters opinion for this report: *

Has this case already been reported to the VMD via the “Yellow form” SSARS scheme? (If applicable to a suspected adverse event or lack of efficacy)

Yes

No

Reference number (if known)

Do you require a discussion regarding this case? *

Yes

No

Please provide your specific queries relating to this report: *

Have you previously spoken to MSD Animal Health regarding this case? *

Yes

No

Case reference number

Please provide photos showing
fault as best as possible:

Add a new file

Please attach any further relevant documents including reports, correspondence or photos.

Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png pdf doc docx.

I understand that clinical histories SHOULD NOT be uploaded.

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Registered office: MSD Animal Health UK Limited, Walton Manor, Walton, Milton Keynes MK7 7AJ, UK. Registered in England & Wales no. 946942.

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