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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?*
Does Revance have permission to contact you about the report?*
Does Revance have permission to contact you about the report?*

Choose A Contact Method*
Does Revance have permission to contact the treating physician about this report?*
Does Revance have permission to contact you about the report?*

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Patient Information

Provide the patient’s information*

(Please fill out as much information as possible)

Section Break

Section Break


MM slash DD slash YYYY

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

Product Actions
 
There are no Listed Products.

Maximum number of listed products reached.

Product Actions
 
There are no Listed Products.

Maximum number of listed products reached.

Product Actions
 
There are no Listed Products.

Maximum number of listed products reached.

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Event Information

MM slash DD slash YYYY
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
MM slash DD slash YYYY
Did the patient receive treatment for the event?
Name of Treatment Dose, frequency and duration of treatment Actions
   
There are no Entries.

Maximum number of entries reached.

Did the patient undergo any laboratory or diagnostic tests?
Name of Test Actions
 
There are no Entries.

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Patient History

Did 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.
Name of Other Filler or Cosmetic Procedure When was the treatment? Actions
   
There are no Entries.

Maximum number of entries reached.

Was the patient allergic to any drug or food?
Name of Drug or Food Actions
 
There are no allergies.

Maximum number of allergies reached.

Was the patient receiving any other medications at the time of the event?
Medication Name Actions
 
There are no Entries.

Maximum number of entries reached.

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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
Please click here if you do not want to receive a copy of the PDF report. Thank you.
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