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Complaint Information
Date
MM slash DD slash YYYY
Name
*
First
Last
Phone
*
Email
*
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
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Colorado
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Delaware
District of Columbia
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U.S. Virgin Islands
Vermont
Virginia
Washington
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Wisconsin
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Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Reason for Complaint
*
Are you the animal owner?
*
Yes
No
Animal Owner Name
*
First
Last
Animal Owner Phone
*
Animal Owner Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Store/Firm Information
Does the complaint involve a store/firm that is located in South Carolina?
No
Yes
Store/Firm Name
*
Store/Firm Phone
Store/Firm Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Product Information
Product Name
*
Product Size/Weight
Lot Code
Manufacturer/Distributor Name
*
Manufacturer/Distributor Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Date Purchased
MM slash DD slash YYYY
Receipt Available?
No
Yes
Animal Information
Number of animals given product
*
Number of symptomatic animals
*
Species/Breed of animal
*
Age(s)
Weight(s)
Gender(s)
Date problem or symptoms first occured
*
MM slash DD slash YYYY
Outcome to date
Describe in detail what happened
*
Describe the animal(s) health prior to the event
*
Has the animal recovered?
*
No
Yes
Date of recovery
*
MM slash DD slash YYYY
Is the animal deceased?
*
No
Yes
Date of death
*
MM slash DD slash YYYY
Veterinary Information
Was the animal observed by a veterinarian?
*
No
Yes
Veterinarian Name
*
Veterinarian Phone
Veterinarian Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Date of first visit related to incident
*
MM slash DD slash YYYY
Date of last visit
MM slash DD slash YYYY
Diagnosis
*
Describe any other information about the veterinarian's diagnosis, test results, treatments, suspected cause of the event, etc.
Supplemental Documents
Do you have supplemental documents?
*
No
Yes
File Upload
If you have supplemental documents you wish to share, please upload here.
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Select files
Accepted file types: jpg, gif, png, pdf, Max. file size: 100 MB, Max. files: 10.
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