First Name *

Last Name *

Email *

Phone

Product name *

Batch Numer *

Message *

I confirm that the report I am submitting concerns a Serious Advers Event as defined below by MoCRA*

*Serious Advers Event: an adverse event that

(A) results in:death; a life-threatening experience; inpatient hospitalization; a persistent or significant disability or incapacity; a congenital anomaly or birth defect; an infection; or significant disfigurement (including serious and persistent rashes, second- or third-degree burns, significant hair loss, or persistent or significant alteration of appearance), other than as intended under conditions of use that are customary or usual; or

(B) requires, based on reasonable medical judgment, a medical or surgical intervention to prevent an outcome described in (A) above.

I have read the Privacy Policy, specifically in reference to the section “Data from adverse event reports”
I consent to the processing of data according to the Cosmetovigilance Data Processing Notice.

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We appreciate you contacting us. One of our colleagues will get back in touch with you soon!

Have a great day!

Adverse Event Reporting Form

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