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.

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* 1. I have read and understand the recall instructions provided in the March 7, 2022 letter.

Yes

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* 2. I have checked my stock and have quarantined all inventory of the affected units.

Yes

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* 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.

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* 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:

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* 5. Please specify the date and method of notification. Skip question if not applicable.

Date:

Method of notification:

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* 6. Any adverse events associated with the recalled product(s)?

Yes

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* 7. If yes, please include product name and batch and a description of adverse events:

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* 8. Please check the appropriate box(es) to describe your customer category

Clinic/Prescriber

Patient

Other (please specify)

Voluntary Recall Response Form

Question Title

* 1. I have read and understand the recall instructions provided in the March 7, 2022 letter.

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* 2. I have checked my stock and have quarantined all inventory of the affected units.

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* 3. Indicate disposition of recalled product:

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* 4. Please specify the quantity, date, and method of your returned or destroyed product(s). Skip question if not applicable.

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* 5. Please specify the date and method of notification. Skip question if not applicable.

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* 6. Any adverse events associated with the recalled product(s)?

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* 7. If yes, please include product name and batch and a description of adverse events:

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* 8. Please check the appropriate box(es) to describe your customer category

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* 9. Name:

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* 10. Prescribing Clinic (n/a if patient):

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* 11. Customer Tel. number:

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* 12. Clinic Tel. number: