Report Submission Form for Suspected Unlawful Sales of Pharmaceutical Drugs on the Internet.
Please submit as much information as possible about the website you are reporting.
Website Internet Address (URL) [Required]
Please provide any contact information available from the website (e.g. address, phone, email). Limit: 500 characters.
Describe the reason you are reporting this website [Required Limit: 2000 characters]
In case we need to contact you for more information, please provide as much of the following information as possible (optional).
Daytime Phone Number