連絡先

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.

「*」は必須フィールドを示します

このフィールドは入力チェック用です。変更しないでください。
Consent*
Consent

A. Consumer Information

First Name




Last Name





MM スラッシュ DD スラッシュ 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 スラッシュ DD スラッシュ YYYY


MM スラッシュ DD スラッシュ YYYY

C. Suspect Product


MM スラッシュ DD スラッシュ YYYY

D. Initial Reporter

このフィールドはフォームの表示時には非表示になります
Name*







First Name*




Last Name*




Address



























© Copyright - 2008 – 2025 Biorius Privacy Policy | Legal Disclaimer
電話 電子メール