Adverse Reaction Report

18 Questions (15 – 20 minutes)

Name

Order Number

I am filing this report before the product’s expiration date on the price tag (MM/DD/YY) and within 1 year of purchasing the product.

1. Which specific product caused an adverse reaction?

2. Who purchased the product?(required)

Myself Someone else

3. Who had the reaction?(required)

Myself Someone else

4. What age is the person who had the reaction?(required)

5. What dependency level is the person who had the reaction?(required)

Entirely Reliant On Another To Apply The Product Somewhat Reliant On Another To Apply The Product Completely Independent, Can Apply The Product By Themselves

6. Does User Have Any History of Reactions To Certain Products? If So, What Were The Products and Reaction?

7. Does User Have Any Known Allergies or Sensitivities?

8. Who Approved Product Use Before Application (a Physician or Healthcare Advisor)?

9. Was The Product Applied On An Open Wound or Internally? Please explain:

10. Where (on the body) Was The Product Applied? Please be specific:

11. How Often Was The Product Applied, and In What Quantities? Please be specific:

12. What Date Did User START Applying The Product? (YYYY-MM-DD)

13. What Date Did User STOP Applying The Product? (YYYY-MM-DD)

14. Were There Any Product Use Breaks? If So, How Long Was The Time Between Each Use Break?

15. Please Describe the Reaction in as Much Detail as Possible (Severity, How Much Used, Where Used, Etc.)

16. Upload an image file to show the reaction in detail with a clear, well-lit photo.

Drag and drop or click to select a file.

17. Were Any Other Products Used On The Same Area Around The Same Time?

18. Were Any Remedies Successful in Treating the Reaction?

Thank you for your response. ✨

Adverse Reaction Report

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