"*" indicates required fields 123456 Step 1 of 6 Reporter InformationWhat’s your relationship to the patient?*Choose a relationshipI’m reporting for myselfFamily member, friend or caregiverTreating physician/clinicianNo patient was involved for this reportRevance EmployeeYour Name or Initials* Choose A Contact Method* Phone Email Email* Phone Number*Does Revance have permission to contact the treating physician about this report?* No Yes Unknown Does Revance have permission to contact you about the report?* No Yes Unknown Does Revance have permission to contact you about the report?* No Yes Unknown Name or initials* Phone number*Email* Your Full Name* Choose A Contact Method* Phone Email Email* Phone Number*Who are you reporting on behalf of?*-- Select --Health Care ProviderI'm reporting for myselfFamily, Friend, or Care GiverUnknownDoes Revance have permission to contact the treating physician about this report?* No Yes Unknown Does Revance have permission to contact you about the report?* No Yes Unknown Name or initials* Phone number*Email* Physician's full name* Phone Number*Name of clinic or facility* Doctor's Name* Facility Name Doctor’s Phone Number*Address Doctor's Email* City State*Choose a StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip Code Physician’s Full Name* Phone Number*Name of Clinic or Facility* Doctor's Name* Facility Name* Doctor’s Phone Number*Address Line Doctor's Email* City State*Choose a StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip CodeReporter's name or initials* Reporter's Phone Number*Reporter's Email Address* Facility Name* Facility address* Step 1 of 6 1 2 3 4 5 6 Step 2 of 6 Patient InformationProvide the patient’s information* (Please fill out as much information as possible)Patient's Name or Initials Section BreakPatient GenderChoose a GenderMaleFemaleOtherSection BreakPatient Date of Birth MM slash DD slash YYYY Age Patient’s Ethnicity (optional) Hispanic or Latino Non-Hispanic or Latino Patients’ Race (optional) Asian Black Caucasian Native American Other Step 2 of 6 1 2 3 4 5 6 Step 3 of 6 Product InformationProduct Information Product Actions Edit Delete There are no Listed Products. Add a Product Maximum number of listed products reached. Product Information Product Actions Edit Delete There are no Listed Products. Add a Product Maximum number of listed products reached. Product Information Product Actions Edit Delete There are no Listed Products. Add a Product Maximum number of listed products reached. Step 3 of 6 1 2 3 4 5 6 Step 4 of 6 Event InformationWhen did the event start (provide an approximate date if the exact date is unknown)* Date MM slash DD slash YYYY Body locations of signs or symptoms Did the event result in any of the following?(select all that apply)Doctor or hospital visit Yes No Unknown Name of Doctor or Hospital Contact Phone NumberHospitalization Yes No Unknown Hospital Name* Admission Date* Discharge Date Prolongation of existing hospitalization Yes No Unknown Hospital Name* Admission Date Discharge Date Life threatening illness or immediate risk of death Yes No Unknown Describe the life-threatening illness or medical condition* Permanent damage or disability Yes No Unknown Describe the permanent damage or disability condition* Birth defect or congenital anomaly Yes No Unknown Describe birth defect or congenital anomaly* Death Yes No Unknown Date of Death* MM slash DD slash YYYY Hospital Name (if applicable) Cause of Death* Did the patient receive treatment for the event? Yes No Unknown Name of Treatment Name of Treatment Dose, frequency and duration of treatment Actions Edit Delete There are no Entries. Add Treatment Maximum number of entries reached. What is the outcome to the event(s)?*Choose a recovery statusResolvedResolved with ComplicationsNot ResolvedResolvingUnknownDate of Resolution Describe Complications* Did the patient undergo any laboratory or diagnostic tests? Yes No Unknown Name of Test Name of Test Actions Edit Delete There are no Entries. Add laboratory or diagnostic tests Maximum number of entries reached. Describe the adverse event(s) or product complaint in detail, including any signs or symptoms, diagnosis, lab test results, event treatments, and outcome, when available* Step 4 of 6 1 2 3 4 5 6 Step 5 of 6 Patient HistoryDid the patient receive treatment with other toxin products, fillers, or cosmetic procedures prior to the event? If yes, please provide the name of the product and procedure and date of treatment. Yes No Unknown Name of Cosmetic Procesure Name of Other Filler or Cosmetic Procedure When was the treatment? Actions Edit Delete There are no Entries. Add a Procedure Maximum number of entries reached. Was the patient allergic to any drug or food? Yes No Unknown Name of Cosmetic Procesure Name of Drug or Food Actions Edit Delete There are no allergies. Add allergy Maximum number of allergies reached. Was the patient receiving any other medications at the time of the event? Yes No Unknown Medications Medication Name Actions Edit Delete There are no Entries. Add Medication(s) Maximum number of entries reached. List any other relevant medical history, including pre-existing and concurrent medical conditions, and concomitant medications Step 5 of 6 1 2 3 4 5 6 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 A copy of the report will be sent to the following email address* Please click here if you do not want to receive a copy of the PDF report. Thank you. Please click here if you do not want to receive a copy of the PDF report. Thank you. Unique ID Step 6 of 6 1 2 3 4 5 6
