Adverse Events

Please only use in cases that qualify as Serious Adverse Events. For other inquiries that do not qualify as Serious Adverse Events, please use a different tab.

※ Serious Adverse Event:

An adverse event that

(A) results in:

- death;

- a life-threatening experience;

- inpatient hospitalization;

- a persistent or significant disability or incapacity;

- a congenital anomaly or birth defect;

- an infection;

- significant disfigurement (including serious and persistent rashes, second- or third-degree burns, significant hair loss, or persistent or significant alteration of appearance), other than as intended under conditions of use that are customary or usual;

(B) requires, based on reasonable medical judgment, a medical or surgical

intervention to prevent an outcome described in (A) above.

Section A : Product Information (1/4)

* For all other data fields please provide information, if available. ONLY fields with * are mandatory.

1. Please enter product information.

Product Name *

Purchase route

Off-line
On-line(Amazon, etc.,)

Expirarion date *

Lot number *

Please enter the letters and numbers printed near the expiration date on the product or its packaging.

Purchase date *

Net Contents

Place of purchase *

Product Availability *

2. Please upload the product image. (jpg, jpeg, gif, bmp, png, pdf) *

Choose file or drag here

Supported format: JPG, JPEG, PNG, GIF, SVG, PDF.

Section B : Problem Information (2/4)

* For all other data fields please provide information, if available. ONLY fields with * are mandatory.

1. Please enter problem information.

Outcome attributed to Adverse Event *

Death
Life-threatening
Disability, Incapacity
Hospitalization
Infection
Other Serious events

※ Other Serious events: Serious and persistent rashes, second- or third-degree burns, significant hair loss, or persistent or significant alteration of appearance.

Date of event *

Initial use date *

Date of diagnosis *

Usage amount(amount, frequency) *

Application area *

2. Please describe adverse events/problems as many details as possible. (Max. 3000 characters) *

3. Please upload relevant data such as a medical records.
※ Caution: Hospital name must be clearly identified *

Choose file or drag here

Supported format: JPG, JPEG, PNG, GIF, SVG, PDF

Section C : Patient Information (3/4)

* For all other data fields please provide information, if available. ONLY fields with * are mandatory.

1. Please enter patient information.

Patient Name *

Sex *

Male
Female
Decline to answer

※ The sex that a person has or was assigned to at birth.

Gender

※ The gender that a person considers themselves to be (e.g., Cisgender, Transgender, Others)

Age *

Date of birth *

Weight(Unit) *

Weight *

Ethnicity

Hispanic/Latino
Not Hispanic/Latino

Race *

White
Black
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Some Other Race
Two or More Races

Race *

2. Please list all allergies. (Max. 1000 characters) *

3. Please list known medical conditions including preexisting disease. (Max. 3000 characters) *

Section D : Confirm Information (4/4)

* For all other data fields please provide information, if available. ONLY fields with * are mandatory.

1. Please enter confirm information.

Reporter Name *

State *

City *

Street Address *

ZIP Code *

Telephone number *

E-mail address *

Confirm E-mail *

1) The data and information in this submission have been reviewed and, to the best of my knowledge, are

certified to be true and accurate.

I Agree *

2) I consent to providing my sensitive personal information (including sex, gender, age, address, and

medical records) for the purpose of reporting adverse events.

I Agree *

Your submission has been successfully received.

Thank you for providing all the information regarding the adverse events.

We appreciate your effort and apologize for any inconvenience caused.

Your submission has been successfully received.

Thank you for providing all the information regarding the adverse events.

We appreciate your effort and apologize for any inconvenience caused.