Adverse reaction form

Adverse Event Report Form

Please complete the following form and return to your sales representative for patient reaction:

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

2. Age range: *

11-20 years old 21-30 years old 31-40 years old 41-50 years old 51-64 years old 65+ years old

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): *

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

5. Using product start date *

6. Using product stop date *

How long did the reaction last before being resolved? *

Practice Information

1. Location name: *

2. Staff member name: *

3. Email: *

4. Phone #: *

5. Date of patient report: *

CONFIDENTIAL & PROPRIETARY INFORMATION