"*" 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/clinicianRevance 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 Your name or Initials* Choose A Contact Method* Phone Email Email* Phone Number*Are you reporting on behalf of a doctor?* No Yes 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 DakotaOhioOklahomaOregonPennsylvaniaRhode 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 DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip Code Step 1 of 6 1 2 3 4 5 6 Step 2 of 6 Patient InformationProvide the patient’s information* (please fill at least one of the fields below)Patient's Name or Initials Patient GenderChoose a GenderMaleFemalePatient Date of Birth MM slash DD slash YYYY Patient Age Under 21 21 or Over 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 Received Actions Edit Delete There are no Listed Products. Add a Product Maximum number of listed products reached. Product Information Product Received 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* Did the event result in any of the following?(select all that apply)Doctor or hospital visit Yes No Name of Doctor or Hospital Contact Phone NumberHospitalization Yes No Hospital Name* Admission Date* Discharge Date Prolongation of existing hospitalization Yes No Hospital Name* Admission Date Discharge Date Life threatening illness or immediate risk of death Yes No Permanent damage or disability Yes No Birth defect or congenital anomaly Yes No Death Yes No Date of Death* DD slash MM slash YYYY Hospital Name (if applicable) Cause of Death* Did the patient receive treatment for the event? Yes No 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 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, and the location* Step 4 of 6 1 2 3 4 5 6 Step 5 of 6 Patient HistoryDid the patient receive treatment with other fillers, or cosmetic procedures prior to the event? Yes No 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 Name of Drug or Food* Start Date* Was the patient receiving any other medications at the time of the event? Yes No Medications Medication Name Actions Edit Delete There are no Entries. Add Medication(s) Maximum number of entries reached. 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 Please enter your email to continue* Unique ID Step 6 of 6 1 2 3 4 5 6 Δ
