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Complaint Record Form

Type of supply
Classification (if applicable)
Did you use any other cosmetic products (including make-up) on the day of occurence?
Do you use any anti-aging or acne products on a daily basis
Have you had a facial or other facial cosmetic treatment (e.g. masks, peels, dermabrasion) in the last ten days
Have you recently exfoliated your skin or used any topical products (i.e. creams, gels, serums, washes) containing Alpha Hydroxy Acids (AHAs) (e.g. glycolic, lactic acid), Beta Hydroxy Acids (BHAs) (e.g. salicylic acid) or products containing retinol or benzoyl peroxide in the last ten days
Do you use any products containing essential oils or fragrances on a daily basis?
Was a doctor, pharmacist, or other healthcare professional consulted?