ExSell Credit Request Form
Please complete the form below should you wish to submit an item(s) for a credit request.
Pharmacy Contact Information
Pharmacy Name:
*
Request submitted by:
*
Date of Claim:
*
-
Month
-
Day
Year
Date
Main Pharmacy Email Address*
*
*Credit request confirmation will be sent to this email address
Invoice Information:
Reason for Credit:
*
Please Select
Damaged in Transit
Short Dated
Faulty
Short Sent
Incorrect Product
Please note damaged in transit items will need photo evidence. Please upload image.
Invoice Number:
*
Customer Order Number:
*
Invoice Date:
*
-
Month
-
Day
Year
Date
Invoice Amount (ex.GST):
*
If Damaged in Transit or Faulty please upload image here:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Will the invoice require a full credit?
Please Select
Yes
No
Please list item(s) to be credited below:
*
Item Code
Quantity
Batch Number
Product 1
Product 2
Product 3
Product 4
Product 5
Product 6
Product 7
Product 8
Product 9
Product 10
Submit
Should be Empty: