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Injury Details
Please describe the injury you experienced (please share as much information as possible).*
When did the injury occur?*
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Did you seek out medical treatment?*
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What treatment did you receive?*
What is the name of the Doctor you saw and the address of the hospital or clinic you visited?*
Do you still have a sample of the product?*
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We would like to retrieve the object, and will arrange for Purolator to come pick up the object. Best date and time of day for pick up:*
You may also send us an image of the foreign object via the attachment tool available at the end of this online form.
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Illness/Allergy Detail
Please describe the reaction or symptoms you experienced.*
What food allergies do you have?
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Approximately how long did your symptoms last?*
What other food was consumed within 2 hours of eating the product?
Did you seek out medical treatment?*
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What treatment did you receive?*
What is the name of the Doctor you saw and the address of the hospital or clinic you visited?*
Do you still have a sample of the product?*
- Yes
- No
We would like to retrieve the object, and will arrange for Purolator to come pick up the object. Best date and time of day for pick up:*
You may also send us an image of the foreign object via the attachment tool available at the end of this online form.
Pick-up Location Address (if not the same as home address):*
Foreign Material in Product Detail
Please describe the foreign material.*
Was any injury sustained from the foreign material?*
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Did you seek out medical treatment?*
- Yes
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What treatment did you receive?*
What is the name of the Doctor you saw and the address of the hospital or clinic you visited?*
Do you still have a sample of the product?*
- Yes
- No
We would like to retrieve the object, and will arrange for Purolator to come pick up the object. Best date and time of day for pick up:*
You may also send us an image of the foreign object via the attachment tool available at the end of this online form.
Pick-up Location Address (if not the same as home address):*
Product Information
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Product:*
Product:*
Purchase Details
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questions? comments? we’d love to hear from you

Injury Details

Illness/Allergy Detail

Foreign Material in Product Detail

Product Information

Purchase Details

Contact Details

Comments

Attachments

Mailing List

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questions? comments?
we’d love to hear from you