1. Step 1
    About You
  2. Step 2
    About the Incident
  3. Step 3
    Affected Person
  4. Step 4
    About the Device
  5. Step 5
    Finish and Submit
Are you a health professional?
Automatically populate my details? Help
Please provide your name and at least one contact method
First Name: *  
Surname: *  
What is the preferred contact method?
Email: *  
What is your main professional category?*  
Position: * 
Company / Institution: * 
Address Line 1:
Address Line 2:
Town / Suburb:
State / Province:
Are you reporting this incident on behalf of someone else (the initial reporter)? Help
Please confirm your contact and privacy instructions Help
Are you happy for the device company to know your identity?
Are you happy for the device company to contact you about this incident?
Who should the TGA contact for more information regarding this incident?
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