Tell us about yourself and the type of report you're filing.

Type of Report *

Adverse Event
An unwanted side effect or health problem after product use
Product Quality Problem
Defect, contamination, labeling error, or quality concern
Both
A product problem that may have caused an adverse event

Your Role *

Full Name *

Email Address *

Phone

Date of this report *

Provide details about the individual who experienced the adverse event. Check "Same as reporter" if you are the affected person.

Patient Initials *

Age *

Biological Sex *

Weight (lbs) *

Known Allergies or Pre-existing Conditions

Identify the mushroom product suspected to have caused the adverse event. Provide as much detail as available.

Product Name *

Mushroom Type(s) *

Product Form *

Lot / Batch Number *

Expiration Date

Dosage / Amount Taken

Duration of Use

Where Purchased

Purchase Date

Provide any other relevant details. All fields in this section are optional.

Other Products Used Concurrently

Relevant Lab Tests or Medical Records

Has this been reported to the FDA? *

Additional Comments

I confirm this information is accurate to the best of my knowledge *

By submitting, you agree that the information may be used for safety review and regulatory reporting.

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Capsule Product