amika® Shampoo Recall Consumer Entry Form

Directions: Please complete the form below to submit a request for reimbursement. For best results, it is recommended that the form is completed on a mobile or tablet device with a rear-facing camera. You will need to take two photos of the recalled product to process your request. You will receive an email confirmation once submitted.

*If you're not on a device with a camera, you can scan the QR code with a mobile device to take you to this page.

*Where did you purchase your Shampoo:

*First Name:

*Last Name:

*Email Address:

*Reenter Email Address:

*Phone:

*Country:

*Street Address:

Apt, suite, or floor#:

*City:

*State/Province:

*Postal Code:

*Client ID:

*PO Number:

For each type of product to be reimbursed and destroyed, select the Product Name and enter the quantity you have on-hand. To add additional rows, select the '+' button at the end of the row.

		Product Name	Quantity

*Do you have a receipt:

Next, please use a permanent marker to write the word "DAMAGED" across the front label of all units of affected product. You will then need to take a photo showing all affected product grouped together.

Please click the blue button below to enable your camera. Accept the permission if prompted. Take photo(s) as instructed. Click/tap the green capture button(s) and view photos below.

If you need to re-take a photo, simply point the camera view at the subject and click the green take photo button(s) again.

Photo of front labels

The amika Mirrorball High Shine + Protect Antioxidant Shampoo is not classified as a hazardous product, thus disposal of the product is not required to follow disposal instructions for hazardous waste. Proper disposal can be initiated by pouring the product down the drain and discarding the product packaging in the trash or recycling through TerraCycle®.

*I hereby certify that the above information regarding the quantity is true and accurate to the best of my knowledge and I have disposed of the product as described in the disposal instructions referenced above.