RETURN AUTHORIZATION FORM

Business Name:*

Customer ID:

Date:*

Invoice:*

Select your Pharmsource Account Manager (if applicable):

Items:*

Additional Notes / Details:

Optional: If you have any files that might help us understand the issue (photos, screenshots, supporting documents), feel free to upload them here.

The aforementioned customer guarantees all products returned to Pharmsource, LLC have been stored, handled and shipped in accordance with manufacturer guidelines, Federal, State and Local Laws, including the Prescription Drug Marketing Act requirements of f.s. 499.0121 and the rules adopted there under while in the purchaser's custody and control. Any products not meeting the above requirements are not eligible for return or credit. All products returned must be authorized in advance. Pharmsource, LLC reserves the right to return or destroy products that are ineligible for credit or sent without prior authorization. A 20% restocking fee will be charged for all returned product after 5 days from the date of receipt. An additional 10% fee will be charged for each week thereafter.
This product is being returned in accordance with the Drug Supply Chain Security Act (DSCSA). The serialized data provided (GTIN, serial number, lot number, and expiration date) matches the original transaction information. The product was originally purchased from Pharmsource LLC, and is being returned by the original purchaser. All data has been verified through EPCIS and meets the requirements for saleable return.

Customer Name:*

Customer Signature:*