Nirvel Professional Serious Adverse Event Reporting Form
⚠️ IMPORTANT NOTICE
If you are experiencing a medical emergency or life-threatening symptoms, please seek immediate medical attention or contact your local emergency services.
This form is intended for reporting serious adverse events related to Nirvel Professional products. Please complete the form with as much detail as possible to help us investigate and address the issue.
Contact Information
Full Name (Required): Phone Number (Required): Email Address (Required): Mailing Address (Optional):
Preferred Contact Method: PhoneEmail
Are you reporting on behalf of someone else?: YesNo
If yes, please provide your name and relationship to the person affected:
Product Information
Name of Product Involved (Required): Product Type (e.g., Hair Dye, Shampoo, Styling Product, etc.): Batch/Lot Number (if available): Date of Purchase: Place of Purchase (store name, website, distributor, etc.):
Was the product used according to the instructions provided? YesNoNot sure
How was the product applied/used (e.g., at home, at a salon, etc.)? How many times have you used this product before the adverse event occurred?
Adverse Event Details
Date the Adverse Event Occurred (Required):
Time Between Product Use and Adverse Event Onset (Required): ImmediatelyWithin 1–3 hours3–12 hours12–24 hoursMore than 24 hours
Description of the Adverse Event (Required):
(Please describe the symptoms, reactions, and circumstances in as much detail as possible.)
Severity of the Adverse Event (Required): MildModerateSevereLife-Threatening
Did you experience any of the following symptoms? (Select all that apply): Skin irritation (e.g., rash, redness)Swelling (e.g., face, scalp, eyes)Breathing difficultiesBurns (e.g., chemical or thermal)Hair loss or damageEye irritation or injuryOther (please specify):
Was medical attention required? (Required): YesNo
If yes, please provide the following details (if known):
Name of Healthcare Provider/Clinic: Diagnosis or Treatment Given:
Was hospitalization required?: YesNo
Did you stop using the product after the adverse event? YesNo
Health and Lifestyle Information
Do you have any known allergies or sensitivities (e.g., to specific ingredients, products, or environmental factors)?
NoYes (please specify bellow)
Were other products, cosmetics, or medications being used at the same time?
NoYes (please list bellow)
Do you have any pre-existing medical conditions that may have contributed to the adverse event?
Have you previously used other Nirvel Professional products without any issues?
NoYes
Follow-Up Information
Have you reported this issue to any other regulatory body or organization (e.g., health department)?
NoYes (please provide details below)
Would you like to be contacted for follow-up questions or updates?
YesNo
How would you like us to update you about the status of this report?
EmailPhoneOther (please specify):
Attachments
Please upload any relevant files to support your report (e.g., photos of the product, receipts, medical documents):
Consent to Process Information (Required): I consent to Nirvel Professional processing my personal data for the purpose of investigating this report. Signature (Required): Date (Required):
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