Client Product Quality Complaint Form
Product Quality / Product Defect Report:
Complete this complaint form using the same section headings and wording as closely as practical.
Use the attached reference document for structure and field order.
Client / Practice and Contact Details
Client/Practice Name
*
Contact Person
*
Email Address
*
example@example.com
Telephone Number
*
Please enter a valid phone number.
Format: 000 000 0000.
Preferred contact method
Email
Telephone
WhatsApp
Other
Product Details
Product name
*
Strength
*
Dosage form
Batch number, if applicable
Expiry date, if applicable
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Date product was supplied
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Quantity affected, if available
Type of Complaints
Tick all that apply:
Complaint type
*
Product appearance concern
Unusual smell/taste/texture
Colour change/separation/precipitation
Suspected incorrect product
Suspected incorrect strength
Labelling concern
Packaging or container defect
Device malfunction
Suspected contamination
Stability concern
Delivery or storage concern
Other
If other, specify
Date issue was noticed
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Was the product used?
*
Please Select
Yes
No
Unknown
Has use of the product been stopped?
Please Select
Yes
No
Unknown
Not applicable
Is the product available for return or inspection?
Please Select
Yes
No
Are photos attached?
Please Select
Yes
No
Storage conditions, if relevant.
Please Select
Refrigerated
Room temperature
Other
Upload supporting photos or documents
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Detailed description of complaint
*
Additional comments
Adverse Reaction / Follow-up Actions
Was any adverse reaction or patient harm reported?
*
Please Select
Yes
No
Unknown
If yes, has an ADR report also been submitted or requested?
Please Select
Yes
No
Not applicable
Was the product withheld from use?
Please Select
Yes
No
Not applicable
Replacement requested?
Please Select
Yes
No
Credit requested?
Please Select
Yes
No
Other action taken
Client Declaration Details
Name
*
Designation
*
Signature
*
Date
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Submit
Submit
Should be Empty: