Finlandia — Product Return & Adverse-Effect Report

I have not yet left the store (this is an in-store change of mind).

Only tick this if you are still inside the store — staff will verify at the counter before processing.

How can we find your purchase? *

Enter either one — you only need your online order number OR your in-store receipt number.

Order number (online orders)

In-store receipt number (in-store purchases)

Seal status when you received it after purchase *

Has the product been opened / used? *

Yes No

Confirm email *

Please type your email again — pasting is disabled so we can catch typos.

Province / Territory

Already reported to the manufacturer? *

Yes No

Organization / clinic (if applicable)

Product barcode / SKU *

The barcode number on the package (the digits under the bars), or the product SKU — in our store these are the same.

Number of units returned *

Units of this same product AND dosage/strength.

Manufacturer / brand

DIN / NPN (on the label)

Date you started using it *

What were you taking it for? *

What did you notice? (check all that apply) *

Off / unusual smell Off / changed colour Off / unusual taste Abnormal texture / consistency Foreign object / contamination Mould / mold Broken / crumbled / powdery tablets or capsules Separation / leaking contents Other

Please describe the quality issue in detail *

When did you first notice it? (optional)

Age (months, if infant)

Sex *

Medical history (allergies, pregnancy, smoking/alcohol, liver disease, etc.)

What symptoms did you experience? (check all that apply) *

Other symptom — not listed above (please describe)

Have you ever had this reaction to this product before, or had the symptoms reported here before as an existing condition? *

Seriousness (check all that apply)

Needed medical attention Admitted to hospital Life-threatening Disability Birth defect Death

Side-effect start date *

Side-effect end date

Please explain (still recovering)

How soon after taking the product did the side effect start? *

What did you do about it? (check all that apply)

Stopped the product Lowered the dose Saw a doctor or pharmacist Went to the ER or hospital Took other medicine No treatment Other

More about what you did (optional)

Anything else? Tell us in your own words (optional)

Did you stop the product after the side effect? *

If you stopped, did the side effect stop? *

Did you start the product again? *

If you restarted, did the side effect come back? *

How likely is it the product caused the side effect?

Other health products taken at the same time (optional)

Any related test or lab results (optional)

I consent to Finlandia handling this information to process my return and, where applicable, to report to Health Canada and the supplier. *

The information I have provided is accurate to the best of my knowledge. *

Please confirm your answers