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Business Name (if applicable)
Salutation (required)
Name (required)
Address
City
Province Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan Northwest Territories Nunavut Yukon
Postal Code
Country
Phone Number (555-555-5555) (required)
Email Address (your.name@domain.com) (required)
Health Product Type Drug Medical Device Natural Health Product Veterinary Health Product Others
Health Product Authorization Status Authorized for sale in Canada Unauthorized Unknown
Health Product Brand Name (required)
Health Product Licence Number (DIN, MDL,NPN, DIN-HM, notification)
Market Authorization Holder or Manufacturer
Medicinal ingredient/s
Dosage Form (For example: tablet, syrup, injectable, oral suspension, etc) (if applicable)
Alleged Contravening Party (who is marketing) (required)
Date of alleged Contravention (when did you encounter the marketing) (YYYY-MM-DD)(required)
Marketing Medium (where did you encounter this marketing: Website, Facebook, Radio, newspaper, etc.) (required)
Marketing Details (Please provide as much detail as possible about the marketing. For marketing encountered online, please provide the Web site address.) [5000 characters] (required)
Attachments: If you have examples you can provide copies, pictures, audio clips and/or video clips of the marketing. Do you need to be contacted to provide attachments or after review? Yes No
