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Injury Details

Please describe the injury you experienced (please share as much information as possible).*

When did the injury occur?*

Did you seek out medical treatment?*

Yes
No

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):*

Illness/Allergy Detail

Please describe the reaction or symptoms you experienced.*

What food allergies do you have?

When did the reaction/illness occur?*

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?*

Yes
No

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?*

Yes
No

Did you seek out medical treatment?*

Yes
No

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

Brand:*

Product:*

Purchase Details

Have you purchased this product before?*

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Purchase Location

Best Before Date*

Example: 170422KB1 (YYMMDD Plant Shift)

Contact Details

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Comments

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Attachments

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Mailing List

Would you like to receive updates on promotions, new product launches, recipe ideas, and special offers, or to participate in a survey from Lesley Stowe Fine Foods?*

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Do you provide permission for Lesley Stowe Fine Foods to use comments in this form for internal or external marketing purposes, including advertising and social media?*

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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

for all media inquiries contact:

Natasha Townsend, Harbinger

for all retail inquiries contact:

contact us

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

for all media inquiries contact:

Natasha Townsend, Harbinger

for all retail inquiries contact:

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