Complaint form Troy Complaints Reporting Form | TLSF174 Attention: Quality Manager, Troy Laboratories Pty Ltd | Refer to QMS-GEN-013 – Complaints Product Name: * Date Complaint Received: Batch No: Expiry Date: Customer Name: Complaint reply requested: YesNo Contact Number: * Email: * Mailing address: Date complaint detected: Explain where the product was stored and at what temperature: Date Product was Broached: Complaint Sample Available YesNo If No, Explain: Replacement Product Required? YesNo Replacement Product Received / supplied? YesNo Explain the Nature of the Complaint (Tick all applicable): Adverse EventEfficacy IssueSafety IssuePackaging issueProduct LeakageEmpty ContainersDiscolouration of the ProductDelivery IssueOther If you selected Other above please explain: Please explain the complaint in detail below. Complaint sample(s) expected: YesNo Photo(s) expected: YesNoUploaded Upload Photos if available: For Suspected Adverse Events Only Extra information attached YesNo Upload Extra Information: Animal Information Species & Breed: Age: Weight: Other animals affected?: YesNo Number: Details: Troy/Ilium Product used: Dosage: Route of Administration: Product Used as per the label: YesNo Concomitant product use: YesNo Name: Dose: Manufacturer: Batch Number and Expiry Date Treating Vet (If applicable): Vet Name: Practice Name: Completed By: Date:
