771998 Cosmetics
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Adverse Event Reporting Form
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required information
For all other fields please provide information if available.
Consumer
Description
First Name
*
Last Name
*
Phone#
*
Address
*
City
*
State
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Zip Code
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Email Address
*
Reporting Person (if different than the consumer)
Description
First Name
Last Name
Phone#
Address
City
State
Zip Code
Email Address
Product
Product Details
Product Name
*
Product Type
cosmetics
skincare
Shade Name
Item Number
Batch Number
Place where you bought the product from(store name)
*
Date of purchase of the product
*
Description of adverse reaction
*
Date the event occured(approx.)
*
Date of discovery of the adverse reaction(approx.)
Duration of application
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