Patient or Caregiver

Patient or Caregiver

Submit this form anonymously? * *
This is a required field
We will NOT be able to contact you in response to your inquiry.
Have you reported this complaint before? * *
This is a required field
Please include reports made by the pharmacy or patient for the same product.

Case Number (i.e. CC-1234567) *

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First Name *

Please enter your first name {{crossValidationError['yesFirstNameAnonymous'].crossValidationErrorMessage}}

Last Name *

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E-mail *

Please enter e-mail address Please enter e-mail address {{crossValidationError['emailAddressYesAnonymous'].crossValidationErrorMessage}}

Phone Number *

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Please enter the name of the product {{crossValidationError['yesProductNameAnonymous'].crossValidationErrorMessage}}

Reason For Contact *

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Additional Attachment(s) *

You can only attach up to 10MB Following file extensions are allowed: .xls,.xlsx,.doc,.docx,.ppt,.pptx,.pdf,.msg,.eml,.jpg,.jpeg,.png {{crossValidationError['yesAttachmentAnonymous'].crossValidationErrorMessage}}

First Name *

Please enter your first name {{crossValidationError['noFirstNameAnonymous'].crossValidationErrorMessage}}

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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Please enter the name of the product {{crossValidationError['noProductNameAnonymous'].crossValidationErrorMessage}}

Complaint Description *

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Photo(s) of Issue *

Please attach any photos or video of your issue
You can only attach up to 10MB Following file extensions are allowed: .xls,.xlsx,.doc,.docx,.ppt,.pptx,.pdf,.msg,.eml,.jpg,.jpeg,.png {{crossValidationError['noAttachmentAnonymous'].crossValidationErrorMessage}}

Lot Number *

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Is the product available for retrieval? *
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Do you consent to follow-up communication(s) regarding this complaint? *
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Have you reported this complaint before? * *
This is a required field
Please include reports made by the pharmacy or patient for the same product

Case Number (i.e. CC-1234567) *

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First Name *

Please enter your first name

Last Name *

Please enter your last name

E-mail *

Please enter e-mail address Please enter e-mail address

Phone Number *

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Please enter the name of the product

Reason For Contact *

Additional Attachment(s) *

You can only attach up to 10MB Following file extensions are allowed: .xls,.xlsx,.doc,.docx,.ppt,.pptx,.pdf,.msg,.eml,.jpg,.jpeg,.png {{crossValidationError['yesComplaintBeforeAttachment'].crossValidationErrorMessage}}
* mandatory field

First Name *

Please enter your first name

Last Name *

Please enter your last name

E-mail *

Please enter e-mail address Please enter e-mail address

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

Complaint Description *

Photo(s) of Issue * *

Please attach any photos or video of your issue
You can only attach up to 10MB Following file extensions are allowed: .xls,.xlsx,.doc,.docx,.ppt,.pptx,.pdf,.msg,.eml,.jpg,.jpeg,.png {{crossValidationError['noComplaintBeforeAttachment'].crossValidationErrorMessage}}

Lot Number *

Is the product available for retrieval? * *
Do you consent to follow-up communication(s) regarding this complaint? * *
*mandatory field