澳门正规博彩十大排行平台 Product Replacement (U.S. Only)

Please select the appropriate form below.

Only Specialty Pharmacies should complete the Specialty Pharmacy form. Site of Care centers who have purchased product directly from 澳门正规博彩十大排行平台 should complete the Site of Care form.

Requests for product replacement using the forms below are intended for a U.S. audience only.

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Specialty Pharmacy Information

NOTE: If you are a hospital-based Specialty Pharmacy, please complete the Site of Care form

Patient Information

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Specialty Pharmacy Attestation On Behalf of the Patient

Confirmations(Required)
I declare that the information in this form is true and correct.

My patient has requested replacement medication because the Product our pharmacy dispensed to the patient has since been rendered unsaleable by the patient through unintentional, unplanned circumstances. The patient explained to me as follows (please check all that apply*):
Agreements(Required)
I certify this was an unsolicited request and that the patient informed me that they have not used any amount of the unsaleable Product and that (please choose one*):

() For multi-unit packaging configuration, the unused Product pack will be returned to 澳门正规博彩十大排行平台 or the entire Product pack must be destroyed.

If 澳门正规博彩十大排行平台 approves the patient’s request for replacement medication, I shall communicate to the patient that (i) the replacement medication will be provided to the patient at no charge, (ii) there is no purchase requirement associated with the patient’s receipt of the replacement medication, (iii) the replacement medication is not intended as a reward or inducement for the purchase of any product, and (iv) the patient may not resell or transfer the replacement medication to any other individual or entity for any purpose.

By entering my name below and submitting this form, I hereby attest that the information provided in the form above is true and correct.

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Max. file size: 5 MB.
Please upload a single image of Product damage, if available, (jpeg, gif, png, pdf format only, not to exceed 5 MB in size) or check the box to confirm that no photo of Product damage or impairment is available.
No photo available