Complaint Form

Section 1: Customer Information

Name *

Company/Organization

Email *

Phone

Date of Complaint *

Product Model / Part Number *

Lot Number

Expiration Date

Purchase Order or Invoice #

Type of Device *

Detailed Description *

Images or Attachments

List all current medications. Include dose, frequency, and last dose taken when known.

Prescribed Medications

Over-the-Counter (OTC) Medications & Supplements

If you suspect cross-reactivity or interference, please consult our reference table. View Cross-Reactivity Data .

Was the test result confirmed by laboratory testing?

Yes

No

If yes, provide lab confirmation details