Canister Return Form

Please read the following information before proceeding. Questions? Email us at or call 800.541.4102

1.Enter Contact Information in the fields below.

2.Enter Oral Solid Parameters and Canister Failure Criteria: For each problematic canister enter the Drug Name, NDC, and select the category that best describes the issue. Also, enter any comments you feel may help us better understand the problem you’re having with each canister.

3.Request a Talyst RMA/incident number: Call 800-541-4102 or to receive your RMA/incident number. Enter thenumber in the applicable field below.

4.Packaging and Shipment: Safely and securely package the following items;Ship to:

Failedcanister(s)

Corresponding sample pills(as many as necessary to demonstrate the problem)

A copy of this completed form(including the Talyst RMA/incident number)

Company: / Date: / REQUIRED- Talyst RMA/Incident No:
Address: / Phone:
City, State, Zip: / Email:
Qty / Drug Name / NDC
(5-4 format only)
(e.g., 12345-6789) / Problem / Issue
Jams / Multiple Drops / Breaks
Pills / Credit
(Unused) / Other (please specify)

Talyst Canister Department | 11335 NE 122nd Way, Suite 200, Kirkland, WA 98034 | 800.541.4102 FRM-0009 Rev. 19 Page 1 of 2

CANISTER RETURN POLICY

A canistermay only be returned to Talyst foradjustment to accommodatethe specific NDC for which it wasoriginally designed. Talyst will not warrant a canister which has been repurposed to dispense a differing NDC.

If any Talyst-applied labels are removed, or if the canister is damaged due to misuse (e.g. dropped, or poorly packaged during return shipping), Talyst cannot repair the canister by policy. A new canister must be assembledand will be deducted from the remaining canister allotment (or billed if the allotment has been exhausted).

All canisters will be barcoded using industry-standard Code 128 (AC) or DataMatrix (EC) format in order to provide consistency and eliminate unnecessary confusion.

Acute Care (AC) ACRS Canisters Only: Each canister requires a uniquely-programmed ACRS number. If a returned canister requires a complete rebuild or a newly-assembled replacement canister is required, a new unique ACRS number will be assigned and programmed for that canister.

The customer is responsible for the cost of shipping canisters to Talyst. However, Talyst will incur the cost of returning the new or repaired canisters back to you.

Returned canisters will not be accepted without the accompanying, fully-completed Canister Return Form (including Talyst RMA/incident number). Shipments with missing or incomplete forms will be rejected and returned.

If additional information is required for Talyst to understand the returned-canister’s specific failure mode, or reason for return, etc., a representative will contact you via the telephone number and/or email address entered on the supplied return form. However, if at the end of one month we have received no response, the canister willunfortunately be disposed, requiring a replacement canister be ordered separately if so desired.

All canisters are built to an assembly specification for the pill to which they are matched (i.e., it is not always possible to build a short-bodied canister to dispense a drug when the specification dictates a tall canister, etc.).

If requested, Talyst will issue a 1-for-1 credit for any UNUSED canister returned –along with this return form and a valid RMA number. Once a canister has been used, Talyst cannot accept a canister return-for-credit unless its due to a Talyst-generated error.

Upon request, Talyst will provide new customer-applied canister labels to facilitate the dispensing of an alternate NDC (request Talyst form FRM(AC)-0087). However, Talyst will not guarantee the dispensing accuracy of the relabeled canister, and therefore it will not be warranted.

Talyst Canister Department | 11335 NE 122nd Way, Suite 200, Kirkland, WA 98034 | 800.541.4102 FRM-0009 Rev. 19 Page 1 of 2