Adverse Reaction Report Form

Please complete the following form for patient reaction:

Patient Information

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

This field is required

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

This field is required

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

This field is required

Adverse Reaction

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

This field is required

2. Product name: *

This field is required

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

This field is required

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

This field is required

5: Product use Start Date: *

This field is required

Product use Stop Date: *

This field is required

Practice Information

1. Location Name:

2. Staff Member Name:

3. Email:

This field is required

4. Phone Number:

5. Date of patient report (dd/mm/yyyy)

Thank you! Your Form has Been Submitted

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