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Adverse Event Form
If you have experienced an adverse effect from using one of our products, please fill out and submit this form. The FDA may reach out to you and/or your doctor to verify the accuracy of the submission as well as request more details.
• Person Affected
Name:
Street:
City:
State:
Phone:
Email:
• Adverse Event
Death
A life-threatening experience
Inpatient hospitalization
A persistent or significant disability or incapacity
A congenital anomaly or birth defect
An infection
Significant disfigurement
Other (not one of the above)
• Adverse Event Details
• Product
Lip Lightning
Lip Balm
• Purchase Date
• Where Purchased
Amazon
QOC Beauty Website
SUBMIT
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