Your First Name *

Your Last Name *

Name of Your Practice, Company or Organization *

Your Email *

Your Phone Number *

Your Address *

Your City *

Your State or Province *

Your Zip / Postal Code *

Your Country *

Please check ALL appropriate boxes. *

I have read and understand the recall instructions provided in the Recall Notification letter from Premier Research Labs.

I have checked my stock and have quarantined inventory of the aforementioned Product.

How many units of the aforementioned Product have you quarantined? *

How many units have been destroyed? *

Are you aware of any adverse events associated with the recalled Product? *

Yes

If yes, please explain:

Please check the appropriate box(es) to describe you or your business: *

Healthcare practitioner who distributes Premier Research Labs' products

Retailer (including pharmacies, heath food stores, or retailer stores)

Consumer

Please click the statement below to confirm you have discarded all bottles of AloePro (Lot #122121-0137) left in your possession and you have notified your clients (if consumer contact records are available) who purchased AloePro from you to discard their bottles. *

Yes, I confirm that I have discarded all bottles of AloePro (Lot #122121-0137) in my possession and notified my clients who purchased from me to discard them (if consumer contact records are available). Thank you for refunding my purchase.

Your Signature *

Clear