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COSMETOVIGILANCE

Adverse event or product problem

We offer our consumers cosmetic products that are safe and compliant with current regulations. However intolerance to some of the contained ingredients cannot be excluded.

If any undesirable effect occurred after the application of the cosmetic product, we kindly ask you to fulfil the following form.

COSMETOVIGILANCE
Costumer information
* required fields
Name and surname: *
Age: *
Gender: *
Nationality: *
City: *
Address:
Email: *
Phone: *
Adverse event or product problem
Type of report: *
Outcome attributed to Adverse Event: *
(Select a multiple options)
Death
Date of death: *
Life-threatening
Hospitalization
Other serious or important medical events
Required intervention to prevent permanent impairment/damage
Disability or permanent damange
Congenital anomaly/birth defects
Other disease/health issue
Date of event: *
Describe event or problem: *
Additional comments:
Suspect product
Name of the cosmetic product: *
Cosmetic category: *
 
Batch number: *
Purchase address: *
In store
Online
Gift
First use?: *
Yes
No
Frequency of use: *
Period of use
From: *
Until: *
Reaction zone: *
(Select a multiple options)
Scalp
Cheeks
Armpits
Thights
Foot
Neck
Abdomen
Arm
Forearm
Hand
Forehead
Outline mouth
Torso
Legs
Superior eyelid
Inferior eyelid
Mucous
Has the application of the cosmetic product been suspended?: *
Yes
No
Days passed between application and appearance of symptoms: *
Did the reaction got any better after application suspension?: *
Yes
No
While using the cosmetic product, did you assume or use other products (such as medicines, other products herb based, medical herbs, homeopathy, nutritional supplements, other cosmetics, household products, tattoos, etc ...)?: *
Yes
No
Other relevant history, including preexisting medical conditions:
Doctors and relevant information of interest to the previous use of cosmetics (es. allergy, previous reaction to cosmetic product use, etc...): *
Yes
No
In case of medical advice:
Do you have any documentation available or photos to share?:
Yes
No

I have read, understood and accept the privacy policy*.