Clinical Inquiry or Adverse Event
Type of Submission
*
Please Select
clinical inquiry
adverse event report
Patient Name
*
First Name
Last Name
Provider Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Business Name
*
Business Website
*
Detailed description of unwanted or adverse event:
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What product was used?
*
Please Select
PRX Derm Perfexion
PRX-PLUS
Lot#
*
How long have you been using PRX?
*
Please Select
Less than 3 months
More than 3 months
More than 6 months
Who is your sales rep?
*
Has the patient completed their series?
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Please Select
Yes
No
How many treatments have they had?
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If done in combination with another therapy what device was used and what settings/depths did you use?
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How many days between treatments?
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What products were used post treatment and during the series?
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List all medications patient is using:
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If you feel they had an allergic reaction, has the patient been seen by a doctor or dermatologist?
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Before Photo
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Browse Files
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of
Date of Before Photo
*
After Photo
*
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of
Date of After Photo
*
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