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Bad or unwanted reactions when using a cosmetic product

Cosmetic Product Safety – Reporting Health Issues:

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

Please pay attention that it is not necessary to answer all the questions (or fill in all the information). The more information we have, the better and faster we can assist you, but nothing is mandatory.

A. PATIENT INFORMATION (in confidence)

Name
MM slash DD slash YYYY
Sex
Ethnicity
Gender: Enter the patient’s current gender (how the patient thinks of themself).

B. ADVERSE EVENT OR PRODUCT PROBLEM

Type of Report (check all that apply)
MM slash DD slash YYYY
MM slash DD slash YYYY

C. SUSPECT PRODUCT

MM slash DD slash YYYY

D. INITIAL REPORTER

Name(Required)
Address
This field is for validation purposes and should be left unchanged.