Return Response Form
Add multiple lots by clicking on [+] button
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Please check ALL appropriate boxes.
I have read and understand the recall instructions provided in the letter.
I have checked my stock and have quarantined inventory consisting of Product(s); Lot(s);
Indicated disposition of recalled product:
returned;
held for return;
destroyed;
relabeled;
quarantined pending correction;
Returned; IF different than indicated: specify quantity, date and method:
Held for Return; IF different than indicated: specify quantity, date and method:
Destroyed; IF different than indicated: specify quantity, date and method:
Relabeled; IF different than indicated: specify quantity, date and method:
Quarantined pending correction; If different than indicated: specify quantity:
I have identified and notified my customers that were shipped or may have been shipped this product
Specify date and method of notification:
Any adverse events associated with recalled product?
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Yes
No
If yes, please explain:
Please check the appropriate box(es) to describe your business
wholesaler/distributor
repacker
manufacturer
pharmacy
hospital/medical facility
hospital pharmacies
health care provider/clinic
Name:
*
Title:
*
Company Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Tel. number:
*
-
Area Code
Phone Number
Email
*
example@example.com
Submit
Should be Empty: