Customer/Product Feedback - Verse Cannabis

Product Name *

Product Category *

Contact Type *

Contact Name *

Email *

Phone

Reason for complaint *

Have you experienced adverse effects? *

Yes
No

Adverse Effects

Describe the event experienced *

Did you require medical attention and receive a diagnostic/treatment? *

Yes
No

If Yes, please explain the medical attention and/or diagnostic/treatment *

Did you take any accompanying medication or cannabis products with this product? *

Yes
No

If Yes, please elaborate on medication or cannabis products *

Do you have any past medical history which may relate to the current adverse reactions? *

Yes
No

If Yes, please elaborate on relevant medical history to the adverse reactions *

Did you discontinue the use of the product? *

Yes
No

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For extra information, upload any relevant photo (one photo)

File Upload

Click or drag a file to this area to upload.

Lot # (first line above the barcode titled Lot No.)

Retailer Name

Retailer Location

Thank you for your time, your feedback is important to us. A Verse representative will get back to you as soon as possible to help resolve any issues.

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Adverse Effects

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