Patient or Caregiver

Patient or Caregiver

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First Name *

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Last Name *

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E-mail *

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Phone Number *

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Address Line 1 *

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Address Line 2 *

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City *

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Postal Code *

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Lot Number *

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Pharmacy Name *

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Address Line 1 *

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Address Line 2 *

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City *

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Postal Code *

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Please attach photos of the product, product packaging, and any invoice(s) or receipts *

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Additional Details *

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First Name *

Please enter your first name

Last Name *

Please enter your last name

E-mail *

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Phone Number *

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Address Line 1 *

Address Line 2 *

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City *

Postal Code *

Please enter the name of the product

Lot Number *

Pharmacy Name *

Address Line 1 *

Address Line 2 *

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City *

Postal Code *

Please attach photos of the product, product packaging, and any invoice(s) or receipts * *

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Additional Details *

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