First Name *

Last Name *

Phone *

UK Based *

Email *

Post Code

Relation to animal

Species - e.g. Dog, Cat *

Breed

Name

Age

Sex

Weight (KG)

Product Details

Product Used *

Batch Number

Batch Expiry Date

First Administered *

Last Administered *

Dosage

Frequency Administered

Reason Administered

Administered By

Please list any other concurrent medication(s) *

Problem

Reaction Description *

Reaction Date *

Please list any treatments given to treat this reaction

Has the animal recovered? *

Recovery Date