Adverse Event Form

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Are you reporting a minor (i.e. contact dermatitis or headache) or serious (i.e. death or inpatient hospitalization) adverse event?(Required)

Reporting Person

Name(Required)

First Last

Email(Required)

Enter Email Confirm Email

Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Product Details

Type of Xyrena product(Required)

This form is only for reporting adverse events related to cosmetic products

Approximate Date of Purchase or Receipt of Product(Required)

Where did you purchase the product?(Required)

Order Number

Name of retailer

Name of Product You Believe Caused the Adverse Event(Required)

Adverse Event Details

Date of the Adverse Event(Required)

Did this adverse event result in any of the following? *Documentation requested

Death

A life-threatening experience (i.e. anaphylaxis) that was deemed to be potentially fatal

Inpatient hospitalization

A persistent or significant disability or incapacity

An infection

Significant disfigurement (including serious and persistent rashes, second- or third-degree burns, significant hair loss, or persistent or significant alteration of appearance), other than as intended under conditions of use that are customary or usual.

None of the above

⚠️ You chose "Serious Adverse Event" at the top of this form but have indicated that none of the following occurred: death, a life-threatening experience (i.e. anaphylaxis) that was deemed to be potentially fatal, inpatient hospitalization, a persistent or significant disability or incapacity, an infection, or significant disfigurement.

If you are reporting a minor adverse event, like contact dermatitis or headache, please return to the top of the form and change your selection to "Minor Adverse Event".

What happened?(Required)

Documentation

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 50 MB, Max. files: 5.

Please provide any available documentation

Turnstile

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