Formulir Keluhan
Complaint Form
Yang Terhormat Bapak / Ibu Konsumen Darya-Varia
Demi kemudahan kami untuk melakukan investigasi terhadap keluhan Bapak / Ibu, mohon kerja sama Bapak / Ibu untuk mengisi informasi pada formulir dibawah ini:
An Honored Mr. / Ms. Consumer of Darya-Varia,
In order to investigate your complaint, we would like to appeal your cooperation to fill up the information in this form as below:
Detail Pelapor /
Reporter Detail
Nama Pelapor /
Reporter Name
*
Harap diisi /
This field is required
Nomor Ponsel /
Mobile Phone Number
*
Harap diisi /
This field is required
Alamat Domisili /
Domicile Address
*
Harap diisi /
This field is required
Alamat Email /
Email Address
*
Harap diisi /
This field is required
Usia /
Age
*
Harap diisi /
This field is required
Jenis Kelamin /
Gender
*
Laki-Laki
Perempuan
Harap diisi /
This field is required
Detail Konsumen /
Consumer Detail
Sama dengan pelapor
Nama Konsumen /
Consumer Name
*
Harap diisi /
This field is required
Nomor Ponsel /
Mobile Phone Number
*
Harap diisi /
This field is required
Alamat Domisili /
Domicile Address
*
Harap diisi /
This field is required
Alamat Email /
Email Address
*
Harap diisi /
This field is required
Usia /
Age
*
Harap diisi /
This field is required
Jenis Kelamin /
Gender
*
Laki-Laki
Perempuan
Harap diisi /
This field is required
Informasi Produk /
Detail Product
Nama Brand /
Brand Name
*
ALAXAN
ALLERIN
ASMASOLON
ASPILETS
BIOGESIC
BUDENOFALK
BURNAZIN
CAMASTIL
CARDIOMIN
CARVILOL
CEDOCARD
CEFAZOLIN
CEFUROXIME
CELETEQUE
CETAPAIN
COHISTAN
CONZACE
CORTISON
DALFAROL
DARYACEF
DARYANT-TULLE
DARYAVEN
DARYAZINC
DECOLGEN
DECOLSIN
DEGIROL
DEXTOFEN
DIATABS
DIPITENZ
DISUDRIN
DIVALIN
ENERVON
ENZYPLEX
EPIFRI
ESOZID
ETORIX
FABIFLU
FEBUCID
FENOFLEX
FERLIN
FORTAGYL
FORTI-D
FUNDAMIN
GASTRAN
GRISEOFULVIN
GROWEE
HERBABLEND
HIPERSKIN
HISHIPAGEN
HYALO4
HYAL-SYSTEM
IAL
IMUNPED
IMUNZET
INFLUVAC
ISOPRINOSINE
KENDARON
K-PAIN
LIFEZAR
LIVERPRIME
MEDIAMER
MOLOCO
MOXIVAR
NALGESTAN
NAPREX
NATUR-E
NATUROL
NEOSTRATA
NEOZEP
NIFURAL
NOMATHIC
NORIZEC
OBICAL
OBIMIN
OBIPLUZ
ODACE
ONDAVAR
ORVAST
OSSOPAN
OTHERS
OTOPRAF
OZID
PARATUSIN
PROBI
PRODIVA
PROTEZID
REMIDIA
REMSCAR
RENODERM
RENOGEN
ROSWIN
SALOFALK
SEDAFOL
SILEX
SPASMAL
STOP COLD
SUMAGESIC
SUPER TETRA
SUPERTIN
TELMIZ
THERASORB
THERAVASK
TRIFLUOPERAZINE
URDAFALK
VICEE
WELSUC
Harap diisi /
This field is required
Nama Produk /
Product Name
*
Harap diisi /
This field is required
Nomor Batch /
Batch No.
*
Harap diisi /
This field is required
Tanggal Manufaktur /
Mfg. Date
*
Harap diisi /
This field is required
Tanggal Kedaluwarsa /
Exp. Date
*
Harap diisi /
This field is required
Keluhan /
Complaint
Harap diisi /
This field is required
Pembelian /
Purchase
Tanggal Pembelian /
Purchase Date
*
Harap diisi /
This field is required
Toko Online /
Online Store
Toko Online /
Online Store
Tokopedia
Shopee
Blibli
Lazada
Halodoc
Tiktokshop
Astro
Others
Harap diisi /
This field is required
Nama Toko Online /
Online Shop Name
Harap diisi /
This field is required
Apotek /
Pharmacy
Nama Apotek /
Pharmacy Name
Harap diisi /
This field is required
Alamat Apotek /
Pharmacy Address
Harap diisi /
This field is required
Supermarket /
Supermarket
Nama Supermarket /
Supermarket Name
Harap diisi /
This field is required
Alamat Supermarket /
Supermarket Address
Harap diisi /
This field is required
Lainnya /
Other
Keterangan /
More Information
Harap diisi /
This field is required
Alamat /
Address
Harap diisi /
This field is required
Bukti Lampiran (Foto Produk) /
Attachment (Product Photos)
*
Harap diisi /
This field is required
* Gambar harus jelas
* Maksimal 3 file
* Maksimal total file 5 MB
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