Adverse Event Report

Cosmetic Product Safety :
Canadian Adverse Event Report Form

Your Well-being is Our Priority
We’re truly sorry to hear about your experience and are here to help. To investigate the matter thoroughly and provide the necessary support, we kindly ask for your assistance. Please take a moment to complete the form detailing the adverse reaction you encountered. Once submitted, one of our dedicated experts will review your case and get in touch with you promptly.

Thank you for sharing your concerns with us—we wish you a swift recovery and improved well-being.

Please note that answering all the questions or providing complete information is not mandatory. However, the more details you provide, the better and faster we will be able to assist you.

The data collected by Biorius is processed in compliance with the legal obligations relating to the protection of personal data.

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A. Consumer Information

First Name

First

Last Name

Last

Date of Birth

Sex

Male

Female

Undifferentiated

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. slight allergy, skin irritation, itching, redness,…)

Serious adverse event (e.g. serious allergy, serious burning, important external physical harm, medical treatment required, respiratory problem, hospitalization, life-threatening, …)

Date of Event

Date of this Report

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

D. Initial Reporter

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Name*

First

Last

First Name*

First

Last Name*

Last

Age of the person affected

Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Phone

Email*

Phone

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

Adverse Event Report

Cosmetic Product Safety :Canadian Adverse Event Report Form

A. Consumer Information

B. Adverse Event or Product Problem

C. Suspect Product

D. Initial Reporter

Cosmetic Product Safety :
Canadian Adverse Event Report Form