Medication Recall Notice and Acknowledgment Form
Please review the medication recall notice below and acknowledge your receipt and understanding by completing this form.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Medication Name
*
Lot Number (if available)
Date of Recall Notice
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Have you received and reviewed the recall notice?
*
Yes
No
Actions Taken (select all that apply)
*
Medication returned
Medication disposed
Contacted provider
No action taken
Other
Comments (optional)
Signature
*
Submit Acknowledgment
Submit Acknowledgment
Should be Empty: