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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.

"*" indica i campi obbligatori

Questo campo serve per la convalida e dovrebbe essere lasciato inalterato.
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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MM slash GG slash AAAA

C. Suspect Product


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D. Initial Reporter

Questo campo è nascosto quando si visualizza il modulo
Name*







First Name*




Last Name*




Address




























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