Pharmaceutical Advertisement Complaint Form
Report a concern regarding a pharmaceutical advertisement. Please provide as much detail as possible to assist our review.
Your Full Name
*
First Name
Last Name
Your Email Address
*
example@example.com
Your Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Product or Brand Name Advertised
*
Where did you see the advertisement?
*
Please Select
Television
Radio
Print (Newspaper/Magazine)
Online (Website/Social Media)
Outdoor (Billboard/Poster)
Other
Date you saw the advertisement
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Location or Channel (e.g., TV channel, website, publication)
Describe the issue or concern with the advertisement
*
Upload a copy or photo of the advertisement (if available)
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Submit Complaint
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