Product Event Report

Cosmetic products are amongst the safest products available to the consumer. They are regulated by strict European laws (specifically the EU Cosmetic Products Regulation 1223/2009) that require cosmetics to be assessed for safety and must be safe for use before they are placed on the market. That assessment must be carried out by a scientific expert, a cosmetic safety assessor, whose qualifications are laid down in the cosmetics laws.

5 Squirrels manufacture all products with conformance of ISO 9001:2015 standards certified for the manufacture and supply of cosmetic products incorporating Good Manufacturing Practices (GMP).

It is though true that almost any substance, natural or man‐made, has the potential to produce a reaction in someone, somewhere. Each person is different, and we might find we are allergic to substances that others use or consume without any problems.

If you have had an adverse reaction please complete the form below, this allows us to investigate the issue and ensure safety and consistency in our manufacturing process.

Clinic Name:

Your Name:

Your Email:

Your Phone:

Let us know about the user of the product.

User Age:

User Gender:

User Country of Residence:

Let us know the product used.

Product Name:

Product Brand:

Batch No. :

This can be found on the base of the bottle and is usually a five or six digit code.

Let us know about the product use.

Date of First Ever Use:

Frequency of Use?

Times per day/week/month/year.

Was the product recommended for use after a Skin Consultation?

Yes

No

N/A

Unknown

Product Use Stopped:

Yes

No

N/A

Unknown

Date of Stopping the Product Use:

Re-exposure to the Product:

Positive

Negative

Not Performed

Unknown

Other suspected cosmetic products used concomitantly:

Let us know about the event..

Country of Event:

Date of Onset:

Time from the Beginning of use to onset of First Event:

Time minutes/hours/days/weeks/months.

Time from the last use to onset of first Event:

Time minutes/hours/days/weeks/months.

Was an SPF 50 protection used after application of the product:

If so which Brand:

Reported signs/events:

Reported Diagnosis (if any):

Other:

Event inside/outside area of product application:

If possible, please share images of the event:

Outcome of event.

Outcome:

Resolved

Reducing

Ongoing

Unknown

Other:

If Resolved, Specify Time for Resolution:

Relevant Underlying Conditions.

Does the Patient have Underlying Conditions:

Yes

No

Unknown

If Yes, Specify:

Relevant treatment(s):

Additional Concurrent use of other Products (drugs, food supplements, ...):

Relevant Medical Information/History.

Allergic Diseases, Specify:

Cutaneous Diseases, Specify:

Other Relevant Underlying Diseases, Specify:

Skin Specificities, Including Phototype:

Others (example: specific climatic conditions or specific exposure):

Tell us how was the Case Managed.

Treatment(s) Given:

Drug Prescription, Name of Product, Dose, Duration

Other Measures Taken:

Please give full details.

Tell us About any Complementary Investigations.

Have any Complementary Investigations been Completed?

Yes

No

N/A

Description of Testing:

Please specify (where applicable)...

- Dates of Additional Testing

- Results

Allergic Testing:

Have skin tests been performed with suspected cosmetic products.

Yes

No

N/A

Description of Allergy Testing:

Please specify (where applicable)...

- Product(s) Tested

- Method(s) Used

- Reading

- Result(s)

I hereby give my permission for 5 Squirrels to share the personal information provided by yourself with other service providers in connection with there care, including accessing and sharing their medical, and if applicable, mental health records. I understand that 5 Squirrels and its partner organisations may hold information gathered about the patient from the various agencies and as such their rights under the Data Protection Act will not be affected.

Statement of Consent:

· I understand that personal information is held about the patient.

· You have had the opportunity to discuss the implications of sharing or not sharing information about the patient.

This data will be used in line with the 5 Squirrels Privacy Policy.

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