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Business Name (if applicable)
Newfoundland and Labrador
Prince Edward Island
Phone Number (555-555-5555) (required)
Email Address (firstname.lastname@example.org) (required)
Health Product Type
Natural Health Product
Veterinary Health Product
Health Product Authorization Status
Authorized for sale in Canada
Health Product Brand Name (required)
Health Product Licence Number (DIN, MDL,NPN, DIN-HM, notification)
Market Authorization Holder or Manufacturer
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?