ADVERSE EVENT CONTACT FORM

If you have experienced an adverse event after using one of our products, please complete the form below.

Rest assured that all provided information and data are confidential and will be processed as soon as possible.

Once the form is completed, you will receive a submission confirmation and a copy of your complete form at the email address provided.

Last Name

First Name

Age

Country of Residence

City of Residence

Phone Number

Email Address

Gender

Product Name

Product Size

Batch Number

Where did you purchase this product?

Product Images (Please upload at least one photo of the concerned product)

Date of the first use with this suspected product:

Date of the last use with this suspected product:

Do you routinely buy this product?

Date of adverse event:

Describe event / observed reaction:

Application area:

Neck Chest Wrists Other

The reaction was observed:

Did you apply another cosmetic product in the same area during the day?

Did you expose the area to sunlight after the use of the product?

Relevant test / Laboratory data: