adverse reactions form.

while our products are made for all skin types, including sensitive skin, everyone’s skin is different and reactions are always possible.
as your feedback is extremely important to us, please complete the adverse reactions form below so that we can further assist you and properly deliver feedback to our lab and manufacturers.

* all fields required

1. contact information

first + last name *

email *

2. product information

product name * batch code (please reference below)*

purchase location + date *

3. product usage

date of first use frequency + length of use (i.e. 2x per week) any additional products used? if yes, please list

4. usage history

if applicable, please describe usage history of this product if applicable, please describe usage history of other MALIN+GOETZ products

5. reaction

length of time it took from initial use to showing a reaction reaction description (i.e. appearance or sensation, how long it persisted) known skin sensitivities or allergies?

product usage stopped? *

if yes to the above, please describe any changes after usage stopped attachments

by checking this box, I confirm having read, understood and accepted the privacy policy* .

adverse reactions form.

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