Supplement Radar Data Collection

Supplement Adverse Effects in Australia

submitted_at

Are you located in Australia? (It doesn't matter if the product was purchased overseas, but we can only collect data from Australian residents at this time) *

First Name *

Surname *

Email *

Phone

Postcode

Age *

Gender *

Is it a single ingredient supplement or a multi-ingredient *

Was the supplement purchased online or in store? *

Where did you purchase the supplement (company name) *

What was the reason you purchased the supplement? *

What dose of the supplement did you take? *

What side effects did you experience? *

When did you notice the side effects? *

Did you need to seek medical assistance? *

yesno

If you answered yes to needing medical assistance, what was the outcome?

Do you have any diagnosed health conditions? *

yesno

Please describe briefly which medical conditions

Do you currently take any medication? *

yesno

Please describe medication and dose *

Please upload a picture of the FRONT of the supplement *

Browse

Please upload a picture of the FRONT of the supplement pack. Ensure any text is legible for us :)

Please upload a picture of the BACK of the supplement *

Browse

Please upload a picture of the BACK of the supplement. Ensure that the text is legible for us :)

I would like to be added to the monthly data-wrap newsletter.
[note: we don't send spam emails or sales, you can also unsubscribe at any time]

By ticking this box, I acknowledge and agree to the following:

I understand that my reported data regarding side effects from supplement use will be stored securely in accordance with Australian privacy and health requirements.
My information will be treated with confidentiality and used solely for the purpose of analyzing and reporting adverse effects associated with supplement use.
I consent to the data being shared with relevant authorities only in a de-identified format, ensuring my personal information remains anonymous.
I recognize that my participation is voluntary and that I can withdraw my consent at any time.

I agree with the above terms and provide my consent

I am human *