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.
Format: (000) 000-0000.
Was the patients instructed to use SPF?
Yes
No
Patient Age
*
Business Name
*
Business Website
*
Date of Incident or Treatment
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Month
-
Day
Year
Date
Detailed description of unwanted or adverse event:
*
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?
*
Please Select
Yes
No
How many treatments have they had?
*
If done in combination with another therapy what device was used and what settings/depths did you use?
*
How many days between treatments?
*
What products were used post treatment and during the series?
*
List all medications patient is using:
*
If you feel they had an allergic reaction, has the patient been seen by a doctor or dermatologist?
*
Before Photo
*
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of
Date of Before Photo
*
After Photo
*
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of
Date of After Photo
*
What cleanser is the patient using at home?
Was the patient using Retinoids or other exfoliating acids prior to treatment and if so when did they discontinue use?
What was the last treatment the patient had done prior to receiving PRX? When was it?
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