Quality Defect Complaint Form Quality Defect Complaint Form We would like to hear from you. Please send us a message by filling out the form below and we will get back with you shortly. Quality Defect Complaint Form Type of Report Primary Follow Up Name of medical Dept. contact person Date: Primary Reporter’s Information Name * Title * Profession * Phone No * Address * Fax * Customers Information Initials Profession Address Drug(s) Information Brand Start Date Lot End Date: Comment Out come and possible relatedness of drug Did the event resulted in one of the following: Different Appearance of the drug efected Inhaler or syringe Open blister Missing Leaflet Lower quantity of the drug Details of Quality Defect “Defect Summary Description”: Details of Quality Defect “Defect Summary Description”: If you are human, leave this field blank. Submit Δ