ADVERSE EVENT REPORTING
Dr.'s Remedy Nail Care (Adwill Labs Inc.)
Self Identification
Dr.'s Remedy Nail Care (Adwill Labs Inc.)
Name
*
First Name
Last Name
Today's Date
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birthday
*
-
Month
-
Day
Year
Date
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ADVERSE EVENT INFORMATION
Dr's Remedy Nail Care (Adwill Labs Inc.)
Select all that apply in regard to the problem
*
Had a bad side effect (including new or worsening symptoms)
Used a product incorrectly which could have led to a problem
Noticed a problem with the quality of the product
Did any of the following occur?
*
Life-threatening experience
Hospitalization (initial or prolonged)
Required intervention to prevent permanent damage or impairment
Significant disfigurement
Birth defects
Infection
Death
Other
When did this occur?
*
-
Month
-
Day
Year
Date
Describe the event and how it happened
*
Please list any and all allergies (i.e. food, medication, etc.)
*
If none, type 'NA'
Other diagnosed illnesses, medical history, and/or health conditions
*
If none, type 'NA'
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Product Information
Dr.'s Remedy Nail Care (Adwill Labs Inc.)
Product Name
*
Please Select
Nail Shade *Specify Color Below
Balancing Biotin Gummies
Basic Base Coat
Calming Clear Gel Performing Finish
Caress Antifungal Cuticle Oil
Epic Cuticle Exfoliator
Fearless Therapeutic Foot Balm
Foundational Foot Scrub
Healing Hydration Clear Moisturizing Treatment
Limitless Lotion
Modest Matte
Nourish Nail Serum
Profound Purifier
Radiant Remover
Restore Ridge Repair
Total Two-in-One
If this issue occurred with a nail polish shade, please specify the color below
*
Include the Dr.'s Remedy shade name as listed on the website (i.e. REMEDY Red). If this does not apply to you, type 'NA'.
Date of first use
*
-
Month
-
Day
Year
Date
Date of last use
*
-
Month
-
Day
Year
Date
Do you still have the product?
*
Yes
No
Do you have a picture of the product?
*
Yes
No
Please attach a photo of the front and back labels of the product
Browse Files
Drag and drop files here
Choose a file
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RETAILER INFORMATION
Dr.'s Remedy Nail Care (Adwill Labs Inc.)
Where did you buy this product?
*
If this was purchased at a doctor's office, please specify which one.
Retailer Address (if applicable)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Please list any other comments here
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Name
*
First Name
Last Name
Signature
*
Today's Date
*
-
Month
-
Day
Year
Date
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