First name *

Last name *

Email *

Phone *

Address

Are you the consumer of the product:

If you are not the consumer, please state profession:

If you are not the consumer of the product, please state initials:

Product name (include full name):

Batch Number:

Expiry Date:

Name and Address of premises where product was purchased/used:

Is the product:

Is user aware of precautions on pack:

List any other products used at same time:

Date of occurrence of reaction:

Give brief description of reaction, including location of reaction, symptoms, location of application of product etc.

Time to first signs of reaction (seconds/days etc.)

Duration of reaction

Treatment given/taken: (include product used, usage, duration etc.)

Was use of the product discontinued?

If yes, when?

Was there a noticeable improvement on discontinuation of the product?

Was the product subsequently reapplied?

If Yes, what was the outcome?

Please provide details of any other cosmetics used at the time:

Please provide details of allergies (past and present, if applicable)

Description of any underlying disease, conditions or medication (if applicable)

Was a patch test performed prior to use of the cosmetic product?

Please describe the type of test used and the results of the patch test:

Was a healthcare professional consulted?

Please provide the contact details of the healthcare professional: (note the healthcare professional may be contacted in the case of a serious undesirable effect)

Include healthcare professional report (if applicable) and photos of the product and reaction, if possible.

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Supported format: JPG, JPEG, PNG, GIF, SVG.

Thank you for taking the time to complete this form.

Please note that by your completion of this report form, we understand that you are consenting to the information provided, including your contact details to be stored securely by VOYA. Your contact details will be used solely for the purposes of interaction with you regarding this report.

Voya are compliant with GDPR regulations, our privacy policy is available here.

Thank you for getting in touch!

We appreciate you contacting us. One of our colleagues will get back in touch with you soon!

Have a great day!

Thank you for getting in touch!

We appreciate you contacting us. One of our colleagues will get back in touch with you soon!

Have a great day!

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