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.

*“ zeigt erforderliche Felder an

Dieses Feld dient zur Validierung und sollte nicht verändert werden.

A. Consumer Information

First Name




Last Name





MM Schrägstrich TT Schrägstrich JJJJ

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 Schrägstrich TT Schrägstrich JJJJ


MM Schrägstrich TT Schrägstrich JJJJ

C. Suspect Product


MM Schrägstrich TT Schrägstrich JJJJ

D. Initial Reporter

Dieses Feld wird bei der Anzeige des Formulars ausgeblendet
Name*







First Name*




Last Name*




Address