Darapharma - Complaint

Complaint

CUSTOMER COMPLAINT FORM

Contact Information

First name *

Last name *

Tel (Mobile)*

E-mail Address

Tel (Office)

Address

Fax

Complaint details

Date of receiving complaint

Type of complaint

Details/Message*:

Details of the Product

Name of the product (as in product registration certificate) *

Strength *

Batch number

Expiry date *

I hereby certify that all the above given information are exact and true to the best of my knowledge