COSMETOVIGILANCE FORM

If you experienced an adverse reaction after using G.M. COLLIN products, please share the following information with us so that an agent can contact you as soon as possible.

 

 

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SECTION 1: PURCHASING INFORMATION

 

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1. If your product was purchase on www.gmcollin.com, please give us your order number:

2. If your product was purchased at a spa, please let us know the name of the spa and its phone number:

3. If your product was purchased elsewhere, please provide more information:

SECTION 2: REPORTER'S IDENTITY

(about the person filling out this form)

We will contact you if we need additional information.

 

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SECTION 3: PATIENT INFORMATION

(about the person who had the problem)

 

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SECTION 4: SUSPECT PRODUCT(S)

(about the products)

 

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* If you had a reaction with more than one G.M. Collin product, please fill out the section below; otherwise, leave it empty.

 

SECTION 5: ADVERSE EVENT

(about the problem)

 

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By submitting this form, you acknowledge that the information provided is accurate and you give your free, informed, and voluntary consent for Laboratoires Dermo-Cosmétik Inc. to contact you to complete this report.

 

Thank you! An agent will contact you shortly..