Voluntary Recall Survey

PLEASE READ EACH QUESTION AND SELECT APPROPRIATE ANSWER.

1. Did you receive notification that Pharmacy Innovations recalled your compounded medication? (Please verify with anyone in your household that may have received this notification) * 2. Did you receive or pick up the compounded medication that was recalled? * 3. Do you currently have any of the recalled compounded medication? * 4. If the answer to question 3 is YES, do you intend to return the compounded medication to Pharmacy Innovations or destroy as requested? 5. If the answer to question 4 is NO, please explain your intentions. 6. Have you experienced any illness or injury related to this compounded medication? * Name of person completing questionnaire: * Are you the patient? * If no, please tell us the name of the patient.

If you have any questions, please contact Pharmacy Innovations at 814-838-2102.