HealthSource Return Form

Return Form

P: 410-653-1113 F: 410-415-7004 www.HealthSourceDistributors.com

Fill this out to start a return. Customer service will send your return authorization and a FedEx label.

Applicant Information

Applicant Name *Applicant Email *

A copy of this form will be emailed to the applicant email address when you submit.

Pharmacy Information

Pharmacy Name *

Please list your address as it appears on your BOP license.

Pharmacy Address *City *State *Zip *Pharmacy Phone Number

Return Paperwork

How should we send your return paperwork? *

Fax Email

Items to Return

You can find these on your invoice, or under My Orders in your online account. All fields are required.

Item 1

Date of Purchase *Invoice or Order Number *Product Name *NDC Number *Lot Number *Quantity returning *

Return Policy & Signature

HealthSource Distributors, LLC Return Policy

At Healthsource Distributors we understand occasionally there will be the need to return products you have purchased. Please see the return guidelines and procedures below:

HealthSource Distributors will only accept returns of purchases made directly from Healthsource.
We will accept returns of ordering errors, mistakes and damaged goods within 20 days of the customer receiving the order. Please notify us by completing this return form.
After 20 days, all returns will be subject to a 10% restocking fee and will be accepted for return at our discretion. Return forms received (faxed/emailed) within the 20 day window will not incur this fee.
Returns beyond 6 months from the purchase date will not be accepted under any circumstances.
Refrigerated, Expired, Shop Worn, and Short Dated items will not be accepted for return.
Returns, once received will be processed within 2 business days and credit will then be posted to your account.
Credit will be based upon the invoiced price or the items current market sale price, whichever is the lesser.

To process a return, please follow these steps:

Complete this form in its entirety.
A Return Authorization will be faxed or emailed to you along with a FedEx label
Include the return authorization in the box with the items and affix the FedEx label to your box.
Once the items have been received, your account will be credited accordingly.

The Prescription Drug(s) that I am returning was purchased from Healthsource Distributors, LLC and billed to me on the invoice referenced in this return goods document. I have stored the Prescription Drug(s) being returned in accordance with State and Federal laws and am shipping the product in accordance with same. I declare that I have read the foregoing and that the facts stated in it are true.

None of these items are refrigerated, expired or shop worn, and none were short dated when I ordered them. * I agree to sign this return form electronically. I understand my signature below has the same effect as a handwritten signature, and that I can ask for a paper copy at any time. *

Title *

Signature of Authorized Recipient *

Sign with your mouse or finger.

By clicking Sign and Submit you are signing this form electronically.