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.

Thanks for getting in touch!

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

Have a great day!

Thanks for getting in touch!

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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