FIELDS MARKED WITH A [*] ARE ESSENTIAL FIELDS

NAME/INITIALS*: 

YOU ARE A :* professional patient relative of a patient other medical student

RELATIONSHIP TO PATIENT*:

E_MAIL*:   

COUNTRY*:

WEBSITE/UTILITY INVOLVED*:

HARM PRODUCED*

EVIDENCE ON HARM PRODUCED[LIKE LABORATORY REPORTS/CLINICAL EXAMINATION REPORTS/OTHER INVESTIGATION FINDINGS]*

STEPS TAKEN AFTER HARM WAS NOTICED*:

WHAT WAS THE WEBSITE OWNER's/WEBMASTERS/CYBERDOCTOR's RESPONSE TO THE HARM INDUCED?*

OTHER COMMENTS:

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