ADVERSE REACTION

More information on your regimen:
YOUR COSMETICS / SKINCARE PRODUCT(S) - have you used any other cosmetics and / or skincare products at the same time of your reaction?*

YESNO
PLEASE PROVIDE US WITH THE NAME AND DESCRIPTION OF THE OTHER COSMETICS AND / OR SKINCARE PRODUCT(S)*
YOUR ALLERGENS - descriptions of allergens (past and present if applicable):*
PLEASE DESCRIBE ANY UNDERLYING CONDITION / DISEASE / MEDICATION YOU MAY HAVE*
HAVE YOU CONSULTED A HEALTHCARE / MEDICAL PRACTITIONER REGARDING YOUR REACTION?*

YesNo
PLEASE PROVIDE US WITH THE NAME AND CONTACTED NUMBER OF THE PRACTITIONER*
Please note that the Healthcare professional may be contacted to assist with clinical findings and information.
Please include the Healthcare Professional report as well as photos of the reaction.
HEALTHCARE PRACTITIONER REPORT

Cancelof
PLEASE PROVIDE US WITH PHOTO(S) OF THE REACTION*

Cancelof
I hereby declare that the details furnished above are true and correct to the best of my knowledge and belief and I undertake to inform you of any changes therein, immediately.
YOUR SIGNATURE
Signed by //
{yourName}.
Should be Empty: