Adverse Event Report

Adverse Event Reporting Form

We take your safety and satisfaction seriously. If you have experienced any adverse events related to our products, please fill out the following form. Your feedback is invaluable in helping us ensure the quality and safety of our skincare offerings.

Consumer Information

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

Country

(###)

###

####

Date of Birth

YYYY

Sex/Gender

Weight

Ethnicity

Race

Product Information

Product Name

Do you still have the product?

Date of use?

YYYY

Date of last use?

YYYY

Expiration Date

YYYY

Is this product labeled for single use?

UPC Code

Product Batch No

Retailer Name

Retailer Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Adverse Event Information

About the Problem

When did this event occur?

YYYY

Describe the event and how it happened?

Are you allergic to any medications, food or other products?

Other diagnosed illnesses / medical history / chronic health conditions

Do we have permission to contact you about this report?

Relevant Test / Laboratory Data

Notes

Add notes / observations

Adverse Event Reporting Form

Thank You for Your Submission!