Reporting of Technical Complaints
Designation of Person Recording the Complaint
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Company
*
Name of Pharmacy/Doctors Surgery
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Name of Person Reporting the Complaint
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Representative Name
Representative Email
Email Address - Customer
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Telephone Number - Customer
*
Phone
Date Complaint is being reported
*
yyyy/mm/dd
Name of Product
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Strength of Product
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Pack size of product
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Batch Number of Product
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Expiry date of product
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Description of the complaint in detail
*
Does the patient still have the product?
Is the patient able to provide pictures
*
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