Report a Product Issue
Share details about the product, batch, and any adverse reaction so we can trace and act if needed.
Reporter Information
You are a
*
Consumer
Pharmacy or retailer
Clinician or healthcare professional
Full name
*
First Name
Middle Name
Last Name
Email
*
example@example.com
Phone number
Please enter a valid phone number.
Format: (000) 000-0000.
Country
Please Select
United States
Canada
United Kingdom
Australia
Other
Product Information
Which product
*
60 ml bottle
125 ml bottle
Sachets
Batch or lot number
*
Expiry date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Where did you buy it
Approximate purchase date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Quantity affected
Issue and Reaction Details
Describe the issue
*
Did you experience any discomfort, irritation or reaction?
*
Yes
No
Please describe the reaction
Was medical attention sought?
Yes
No
Do you still have the product and packaging?
Yes
No
Attachments and Consent
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I consent to Antara Kita contacting me about this report and processing my information for this purpose, in line with PDPA.
*
I consent to Antara Kita contacting me about this report and processing my information for this purpose, in line with PDPA.
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