Page 1 of 7 PLEASE NOTE: 1. All sections of this form must be CLEARLY PRINTED in detail to prevent delays. The inability to read the report will result in delays. 2. Please attach clear photos of the affected area. Photo of the whole affected area. Close-up view of the affected skin. Signed Consent form - PAGE 7 These photos will only be utilized for medical analysis within Environ and will t be for commercial usage. 3. This Reaction Report form is to be received by the Customer Service Department later than 5 DAYS after the reaction occurred. All relevant information will be sent to the Customer Service Department via one of the following modes of communication: Email: info@dermaconcepts.com Fax: 508-539-9965 Mail to: DermaConcepts, 168 Industrial Drive, Building 1, Mashpee, MA 02649 please complete the following: date:
Page 2 of 7 distributor: name of stockist: tel : cell : email address: client details: name: email address: address: gender: male female age: 20 & under 20-29 30-39 40-49 50-59 60 and over colour of e: amber blue brown grey green hazel red & violet (as in albinism) other (please specify) natural hair colour: brown black blonde auburn chestnut red grey/white phototype: very fair fair fair - olive olive - medium dark brown black is your skin: oily dry rmal combination
Page 3 of 7 1) allergy history 1.1) are you allergic to or ever had a reaction to any of the following?: any food source Aspirin iodine vitamin E vitamin A sunscreen sunlight citrus fruit multi-vitamins any cosmetic any metals (e.g. gold, silver, titanium, etc.) if to any, please specify: 1.2) have you ever suffered or do you suffer from hay fever? 1.3) have you ever had a positive allergy test? if, please specify: 1.4) do you have or have you ever had any other skin disorders or problems such as acne, psoriasis, eczema, contact dermititis or anything else? if, please specify: 1.5) do you have any auto-immune disease (such as rheumatoid arthritis, SLE [Systemic Lupus Erythematosus], thyroid disease, myositis)? 1.6) have you ever had a skin rash of any kind? 1.7) have you ever had skin cancer or sunspots? (Solar Keratoses)
Page 4 of 7 if you answered to any of the above questions, please provide precise details as to the cause of the problem, the way it presented itself and details such as the date the problem occurred, duration and how it was treated: 2) medication / supplementation 2.1) are you being treated with any of the following? topical corticosteriods oral corticosteroids 2.2) do you take anti-depressant or anti-anxiety medication? 2.3) have you ever taken Accutane / Roaccutane or an equivalent to this medicine? 2.4) have you ever used Differen (Adapalene) on your skin? 2.5) have you ever taken additional vitamin A supplementation? 2.6) have you started any new medications or supplements recently? 2.7) are you currently using HRT (Hormone Replacement Therapy) or the contraceptive pill? 3) vitamin A and antioxidants 3.1) do you presently use Environ products on your skin which contain vitamin A and antioxidants? 3.2) which products were you initially introduced to?
Page 5 of 7 3.3) date of first application: 3.4) which products and/or instruments were you using when the reaction occurred and please indicate how often you applied them daily? 3.5) were you informed and instructed to use low dose vitamin A first and gradually build up the dosage? 3.6) did you fully understand the instructions? 3.7) did you ever use Retiic Acid e.g. Retin A on your skin? 4) nature of the reaction 4.1) did you experience any of the following symptoms: redness? swelling? skin weeping / fluid? stinging or burning? itching? other? please specify: 4.2) how soon after applying Environ products did the reaction occur? 4.3) duration of reaction: 4.4) please give the name of the product you think you reacted to:
Page 6 of 7 4.5) alternative product usage during / before reaction occurred?: 4.6) which area of your skin was affected?: 4.7) have you consulted with a doctor regarding your reaction? if, name of doctor: 4.8) diagsis made / conclusion of reaction: 4.9) did she / he perform biopsy of the skin? 4.10) what treatment / recommendations did the doctor prescribe? (generic names please): 4.11) current status of your reaction?: details of products being returned: lot or batch number: expiry date:
Page 7 of 7 consent form: I understand that n-disclosure by me of material information or the disclosure of misinformation concerning any matter pertaining to my health or skin condition may have adverse consequences. name: signature: therapist / authorised stockist name: date: