Serious Adverse Event Reporting Form |

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:

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?

Date the Adverse Event Occurred (Required):

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

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?

NoYes (please list bellow)

Have you previously used other Nirvel Professional products without any issues?

NoYes

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):

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):