Adverse Event Report Form - Colorescience UK

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Patient Information

1. Name OR initials of the patient/user experiencing AE: *

2. Age Range: *

3. Gender: *

4. Was medical attention or treatment sought? If yes, explain: *

5. Additional Information (ie. topicals used in conjunction with Colorescience): *

Adverse Reaction

1. Description of Adverse event (what was the reaction?): *

2. Product name: *

3. Product lot number (located at the bottom of the product and box): *

Expiration date (located on bottom of product and box): *

5: Product use start date: *

5: Product use stop date: *

6. Has the reaction been resolved? *

How long did the reaction last before being resolved? *

Please explain: *

Practice Information

1. Location Name: *

2. Staff Member Name: *

3. Email: *

4. Phone #: *

5. Date of patient report: *

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