Adverse Event Report

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Adverse Event Report

Cosmetic Product Safety
Reporting Health Issue:

Your Well-being is Our Priority
We understand your misfortune and we are sincerely sorry for you. We will investigate the case, but we need your help: please just fill in the form for the bad or unwanted reactions you encountered and submit it and you will be contacted by one of our experts. Thank you very much for your contribution and we hope you will get well soon.

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Name

This field is for validation purposes and should be left unchanged.

Consent*

I agree to the processing of my personal data.*

Consent

I agree that this data may be shared with the distributor and/or the cosmetic product brand and/or authorities of my country.

A. Consumer Information

First Name

First

Last Name

Last

Date of Birth

MM slash DD slash YYYY

Sex

Male

Female

Undifferentiated

Decline to answer

Ethnicity

American Indian/Alaska Native

Black or African American

Asian

Native Hawaiian/Other Pacific Islander

Hispanic/Latino

Caucasian

Gender: Enter the patient’s current gender (how the patient thinks of themself).

Cisgender man/boy (gender corresponds with birth sex)

Cisgender woman/girl (gender corresponds with birth sex)

Transgender man/trans man/ (female-to-male)

Transgender woman/trans woman/ (male-to-female)

Other gender category

Decline to answer

B. Adverse Event or Product Problem

Type of Report (check all that apply)

Product problem (e.g. defects/malfunctions)

Adverse event (e.g. allergy, irritation, …)

Serious adverse event (e.g. permanent damage, hospitalization, life-threatening, …)

Date of Event

MM slash DD slash YYYY

Date of this Report

MM slash DD slash YYYY

Describe Event or Problem

Additional comments and other relevant history (e.g. allergies, pregnancy, tobacco product use, alcohol use, etc.)

C. Suspect Product

Brand name

Product Name

Lot #

Dose or Amount

Frequency

Expiration Date

MM slash DD slash YYYY

D. Initial Reporter

This field is hidden when viewing the form

Name*

First

Last

First Name*

First

Last Name*

Last

Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Phone

Email*

Adverse Event Report

Cosmetic Product SafetyReporting Health Issue:

A. Consumer Information

B. Adverse Event or Product Problem

C. Suspect Product

D. Initial Reporter

Cosmetic Product Safety
Reporting Health Issue: