Reaction Form

Product/Treatment Identification
Please select the product used and/or treatment performed:*
This is the product that client reacted to
Batch Number*
eg B15G789 - batch located on back of bottle or on crimp of the tube. For treatments type N/A
Qty (1)*
Reason for return (1)
Please select the second product used
Batch Number
Qty (2)
Reason for return (2)
Please select the third product used
Batch Number
Qty (3)
Reason for return (3)
Please select the fourth product used
Batch Number
Qty (4)
Reason for return (4)
Please select the fifth product used
Batch Number
Qty (5)
Reason for return (5)
Please select the sixth product used
Batch Number
Qty (6)
Reason for return (6)

Client identification

the person who experienced the reaction
Sex*

MaleFemaleOther
Age
Full Name

First NameLast Name
Contact details - Phone
Contact details - E-mail
Do we have the person's consent to disclose details of affected person to relevant regulatory & government authorities in your country eg ACCC, TGA, etc?*

YesNo
Please provide your name and details*
The person who completed the form
Email address of person completing the form
example@example.com
Phone Number of person completing the form

Area CodePhone Number
Should be Empty:

Product/Treatment Identification