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severe adverse reactions form.

severe 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 *

date of birth *

sex (select one) *

male female

undifferentiated decline to answer

gender *

cisgender man/boy cisgender woman/girl

transgender man/trans man/ female-to-male (FTM) transgender woman/trans woman/ male-to-female (MTF)

other gender category; please specify:

weight (lb/kg) *

ethnicity (check one) * hispanic/latino not hispanic/latino

race (check all that apply) *

american indian/alaska native asian black or african american

native hawaiian/other pacific islander white

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 * .

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