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Voluntary Recall Response Form
This response form is to be filled out by any customer, both patient and/or clinic that has current physical inventory of products subject to the March 7, 2022 Tailor Made Compounding voluntary recall. Please complete to the best of your ability.
1.
I have read and understand the recall instructions provided in the March 7, 2022 letter.
Yes
No
2.
I have checked my stock and have quarantined all inventory of the affected units.
Yes
No
3.
Indicate disposition of recalled product:
Returned
Destroyed
I have identified and notified my customers that were shipped or may have been shipped this product
I will send a list of my customers who received/may have received this product to support@tailormadecompounding.com. Please notify my customers.
4.
Please specify the quantity, date, and method of your returned or destroyed product(s). Skip question if not applicable.
Quantity:
Date:
Method:
Tracking Number:
5.
Please specify the date and method of notification. Skip question if not applicable.
Date:
Method of notification:
6.
Any adverse events associated with the recalled product(s)?
Yes
No
7.
If yes, please include product name and batch and a description of adverse events:
8.
Please check the appropriate box(es) to describe your customer category
Clinic/Prescriber
Patient
Other (please specify)
*
9.
Name:
(Required.)
*
10.
Prescribing Clinic (n/a if patient):
(Required.)
*
11.
Customer Tel. number:
(Required.)
*
12.
Clinic Tel. number:
(Required.)
Current Progress,
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