Product Return & Adverse-Effect Report

Finlandia Pharmacy and Natural Health Centre

Your safety and privacy come first. Tell us about your return below — fields marked * are required.

1. The return

Order number *

Reason for return *

Seal status

Has the product been opened / used? *

Yes No

2. Your contact information

First name *

Last name *

Telephone *

Email *

Province / Territory

Address (optional)

You are a… *

Already reported to the manufacturer? *

Yes No

3. The product

Product name *

SKU / barcode

Strength

Manufacturer / brand

Lot / batch #

DIN / NPN (on the label)

Where purchased

Date you started using it

Date you stopped

Dose taken

How often

How taken (e.g. by mouth)

What were you taking it for?

4. About the person who had the reaction

Age (years) *

Age (months, if infant)

Sex *

Height (cm)

Weight (kg)

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

5. The side effect

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

Skin & allergic

Rash Hives Itching Swelling (face/lips/throat) Flushing

Stomach & digestion

Nausea Vomiting Diarrhea Stomach / abdominal pain Bloating

Head & nerves

Headache Dizziness Numbness / tingling Drowsiness

Heart & circulation

Palpitations / racing heart Chest pain Blood pressure change

Breathing

Shortness of breath Wheezing Throat tightness Cough

Whole body

Fever Fatigue / weakness Chills Severe allergic reaction

Other symptom — not listed above (please describe)

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

Recovered? *

Describe the side effect (what happened, timing, any treatment) *

6. Consent

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

Thank you. Your report has been received. A confirmation email with a copy of your answers is on its way.

Reference:

Finlandia Pharmacy and Natural Health Centre · 1111 West Broadway, Vancouver, BC V6H 1G1 · members@finlandiahealth.com