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Adverse Events and Product Complaints

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Reporter Information

Choose A Contact Method*

Does Revance have permission to contact the treating physician about this report?*

Choose A Contact Method*
Are you reporting on behalf of a doctor?*

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Patient Information

Provide the patient’s information*

(please fill at least one of the fields below)

MM slash DD slash YYYY
Patient Age

Patient’s Ethnicity (optional)
Patients’ Race (optional)
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Product Information

Product Received Actions
 
There are no Listed Products.

Maximum number of listed products reached.

Product Received Actions
 
There are no Listed Products.

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Event Information

Did the event result in any of the following?
(select all that apply)
Doctor or hospital visit
Hospitalization
Prolongation of existing hospitalization
Life threatening illness or immediate risk of death
Permanent damage or disability
Birth defect or congenital anomaly
Death
DD slash MM slash YYYY
Did the patient receive treatment for the event?
Name of Treatment Dose, frequency and duration of treatment Actions
   
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Did the patient undergo any laboratory or diagnostic tests?
Name of Test Actions
 
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Patient History

Did the patient receive treatment with other fillers, or cosmetic procedures prior to the event?
Name of Other Filler or Cosmetic Procedure When was the treatment? Actions
   
There are no Entries.

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Was the patient allergic to any drug or food?
Was the patient receiving any other medications at the time of the event?
Medication Name Actions
 
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Review and Submit

All steps have been completed. Please take this time to review and submit when ready.

1 Reporter Information
MODIFY
2 Patient Information
MODIFY
3 Product Information
MODIFY
4 Event Information
MODIFY
5 Patient History
MODIFY
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