Adverse reaction form

Request *

Product reference * ?Product reference = the last 5 digits of the bar code; in yellow on the photo at the following link following link : Link

Batch No * ?You'll find it in the following format: “11097-1E091” or “1234567/000” or “1234 A LO 12:34” or “12345678”. In yellow on the photos visible at the following link: Link

Country of purchase *

Place of purchase *

Date of purchase *

Product opening date *

Description of the problem encountered: type of reaction and symptoms * ?Describe the problem you encountered with this product (irritation, allergic reaction, burn, cut, etc.).

Time to onset of adverse reaction *

How many times have you used the product? *

How frequently have you used the product? *

Part of the body where the reaction took place *

Medical care or advice from a health care professional received: * ?By medical care, we mean all types of care/products used to treat these undesirable effects that have been recommended to you by a healthcare professional (application of a cream, taking medication, etc.).

What type(s) of care did you use/receive? *

How did the adverse reaction evolve? *

Did you try using this product again sometime later after the adverse effects? *

Did you experience an adverse reaction again? *

Did you use any other products while using this product? * ?Example: cosmetics, medicines, food supplements, etc.

Do you have a history of allergies, skin diseases or other conditions? If so, what type?

Age

Gender

* Mandatory fields

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