Patient GenderMaleFemaleOther

Product Name *Start typing the product name and choose the matching product from the list. If it is not listed, type “Other / Not listed”.

Adverse Event Description *Provide a detailed description including symptoms, severity and duration.

Relevant Medical History & Allergies *Relevant medical history, chronic conditions, recent illnesses and any known allergies.

Clinic Treatment in the Last 30 Days *Please list any clinic treatment performed during the last 30 days, including treatment type and date if known. If none, write “Not available”.

Current Home Care Used *Please list the skincare/home-care products currently being used, including brand and product name. If none, write “Not available”.

Action Taken *

Current Status *ResolvedImprovingOngoingWorseningMedical attention required

Was Hospitalisation Required? *NoYes

Upload Images (Optional)You can upload up to 5 images related to the reaction, treatment area, product packaging or batch/lot number. Accepted formats: JPG, JPEG, PNG, WEBP. Maximum 15 MB per image.

Reporter Comment (Optional)

I confirm that the information provided is accurate to the best of my knowledge.