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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.

"*" señala los campos obligatorios

Este campo es un campo de validación y debe quedar sin cambios.
Consent*
Consent

A. Consumer Information

First Name




Last Name





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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)




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C. Suspect Product


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D. Initial Reporter

Este campo está oculto cuando se visualiza el formulario
Name*







First Name*




Last Name*




Address




























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