REMS Return Request

Customer Name

Business or Residential?

Business Name

Attn To:

Mailing Street

No PO Box

Mailing City

Mailing State

2 Letter State Abbreviation

Mailing Zip Code

Phone Number

Email

Recipient REMS ID#:

Date Return was Initiated:

Product Name: (use CTRL to select Multiple Products)

Strength, Quantity, NDC: (Rev 5mg, 5 Caps, NDC 59572-0405-00

Len 5mg, 10 Caps, NDC 00480-1242-28

Thal 50mg, 10 Caps NDC 59572-205-94)

Notes:

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