771998 Cosmetics

Adverse Event Reporting Form

* required information
For all other fields please provide information if available.

Description

First Name *

Last Name *

Phone# *

Address *

City *

State *

Zip Code *

Email Address *

Description

First Name

Last Name

Phone#

Address

City

State

Zip Code

Email Address

Product Details

Product Name *

Product Type

Shade Name

Item Number

Batch Number

Place where you bought the product from(store name) *

Date of purchase of the product *

Description of adverse reaction *

Date the event occured(approx.) *

Date of discovery of the adverse reaction(approx.)

Duration of application

Enter the result: