ADVERSE REACTION

Adverse Reaction Reporting

At Dermal Health Science, your safety and satisfaction are our top priorities. If you’ve experienced any adverse reactions while using our products, we want to hear from you. This form allows you to report any issues, so we can better understand and address your concerns. Your feedback helps us ensure the highest standards of quality and effectiveness in our skincare formulations. Please provide as much detail as possible, and our team will review your report promptly. We’re here to assist you in finding the best solution to your skincare needs.
csutomer ID
Full Name*

First NameLast Name
name
Mobile Number*
e.g: +27 797 123 4567
Mobile Number [delete]
E-mail*
Your email address
What is the preferred way to contact you?*

EmailPhone

Order / Purchase Details
Where did you buy your product/s?*

Online from this websiteFrom a Practice
Last order date:

DayMonthYear
Date
your latest order number is:
Is this the order number with the product/s referred to in your adverse reaction report?*

yes, that is correctno, the adverse reaction report refers to a product from another order
What was your order number?*
Order number:*
Please provide the name of the practice where you bought your products*
Date of Purchase:*

DayMonthYear
Date
Date:

DayMonthYear
Date

Please describe in as much detail as possible

product usage
how did you use the product/s?*
Approximately how many times have you applied the product/s before the reaction started?*

Please describe in as much detail as possible

reaction details
Please indicate the location of the reaction:*
How long after you applied the product, did the reaction start (seconds / days)?*
Duration of reaction:*
How long did the reaction last?

Please describe in as much detail as possible

actions taken
Please describe the actions taken or treatments given after the reaction started?*
Did you discontinue the use of the product/s?*

YesNo
Did the reaction improve after you stopped using the product?*

YesNo
Did you reapply the product/s?*

YesNo
What was the outcome after reapplication?*

Please describe in as much detail as possible

your skincare regimen
Details of other skincare products and cosmetics used at the same time:*
Descriptions of allergies (past and present if applicable):*
Description of any underlying disease, condition or medication (if applicable):*

Healthcare Professionals report
Was a Healthcare Professional consulted?*

YesNo
Name and contact details of the Healthcare Professional: *
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 Professional report

Upload files

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Please upload photos of the adverse reaction*

Upload image/s

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Final decleration
Declaration: *

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.
Signature*
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