Complication Reporting

  • Complication Reporting

    Use this form to record any complication or emergency medicine administered, ensuring timely notification and full clinical documentation.
  • Date of Reporting:
     - -
  • Date of Complication:*
     - -
    • ACE Member Details: 
    • Have You Personally Treated The Patient?
    •  -
    • Patients Details: 
    • Gender Identity:
    • Details of The Complication: 
    • Nature of The Complication:*
    • Toxin Complications 
    • Nature of The Toxin Complication:*
    • Brand of Toxin:*
    • Filler Complications 
    • Nature of The Filler Complication:*
    • Filler Brand 
    • Brand
    • Aliaxin®  
    • Product:
    • Belotero® 
    • Belotero® Range
    • Definisse™ 
    • Definisse™ Filler Range
    • Dermafill® Filler Range 
    • Dermafill® Filler Range
    • Ellansé® Product Range 
    • Ellansé® Product Range
    • FILLMED / ART FILLER® 
    • FILLMED / ART FILLER® Range
    • HArmonyCa®  
    • Jalupro Range 
    • Jalupro
    • JUVÉDERM® 
    • JUVÉDERM®
    • JULÄINE™ 
    • Lanluma 
    • Type a question
    • MaiLi 
    • MaiLi Range
    • Neauvia® Filler Portfolio 
    • Neauvu Range
    • Profhilo Range 
    • Profhilo Range
    • Radiesse®  
    • Radiesse Range®
    • Restylane®  
    • Restylane Range
    • Revolax® Filler Range 
    • Revolax Range
    • Revanesse® 
    • Revanese Range
    • Saypha® Product Range 
    • Saypha®
    • Sculptra®  
    • Skinvive™ 
    • SuneKos 
    • SuneKos
    • Teoxane Teosyal 
    • Teosyal RHA Collection
    • Teosyal Puresense Range
    • Teosyal Redensity Line
    • Xela Rederm  
    • Xela Rederm
    • Other Dermal Fillers Not Listed Inc Exosomes & Polynucleotides  
    • Unknown Product  
    • Method/ Application 
    • How Was The Product Administered
    • Anaesthetic
    • Did The Patient Require Hyalase?*
    • Medicines Administered  
    • Hyalase Use
    • ACE Group Owned Medicines 
    • Other Treatments - Not Toxin or Filler 
    • Treatment Or Procedure That Led To The Complication?*
    • Anaesthetic:
    • Nature of Complication - Non Toxin/Filler:
    • Reporting  
    • Have You Administered Emergency Medicines Under SLA with a PSD?*
    • Was Adrenaline (Epinephrine) Administered Under Schedule 19 of the Human Medicines Regulations 2012?
    • Severity of The Complication*
    • Has The Complication Been Resolved?
    • Has The Complication Been Reported?*
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    • Disclaimer

      Information submitted in this form may be shared with relevant third parties, including the Medicines and Healthcare products Regulatory Agency (MHRA), product manufacturers, and authorised pharmacovigilance partners, for the purposes of safety monitoring, regulatory compliance, and investigation of adverse events or product quality concerns. Where possible and appropriate, data will be anonymised before disclosure to protect individual identities. By submitting this form, you acknowledge and consent to the potential sharing of relevant details, anonymised where feasible, in accordance with applicable data protection legislation and mandatory regulatory reporting obligations.

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