Have you experienced any injury from a product or service bought from us?
Yes No Not Sure Prefer not to say
If yes, please briefly describe the injury or discomfort:
Physical injury Emotional distress No injury Other
Have you sought medical attention for the injury?
Yes No Not applicable Prefer not to say
Did you report the incident to our company's customer service?
Yes No Not applicable Prefer not to say
Would you like us to follow up with you regarding this incident?
Yes No
All set, how can we reach you?
Name
Email
Phone
(Details here)
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    Ensuring Your Satisfaction and Safety

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