*required fields
subject
1. contact information.
first + last name
email
2. product information.
product name.
batch code printed on the product. (please reference the below photos)
purchase location + date.
3. product usage.
date of first use.
MM
/
DD
/
YYYY
frequency + length of use.
(i.e. 2 times per week)
any additional products used? if yes, please list.
4. usage history.
if applicable, please describe usage history of this product.
if applicable, please describe usage history of other MALIN+GOETZ products.
5. reaction.
length of time it took from initial use to showing a reaction.
reaction description. (i.e. appearance or sensation, how long it persisted)
known skin sensitivities or allergies?
product usage stopped? (please choose one)
yes
no
if yes to the above, please describe any changes after usage stopped.
Verification
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
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19
20
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