iS Clinical - TREATMENT REACTION QUESTIONNAIRE iS Clinical - TREATMENT REACTION QUESTIONNAIRE iS Clinical- TREATMENT REACTION QUESTIONNAIRE INDIVIDUAL REPORTING Individual Reporting Reaction * Dato * Reporter Email * Phone * Customer Name * Customer Location * CLIENT INFORMATION Is the client? * New Existing Individual who Experienced Reaction * Skin Type * Skin Concerns Being Treated * Date of Last Skin Treatment * Date format: 12/05/22 Results of Last Skin Treatment: * Homecare regimen in use prior to treatment (please include iS CLINICAL and other products, by name below - if applicable) AM - After Midnight (00:00 - 12:00) PM - Past Midday (12:00 - 00:00) Does the patient use any topical prescriptions? * No Yes (please list)Yes (please list) Did the patient use any home skincare devices? * No Yes (Complete Device Information Below) If Yes - The Patient Used Skincare Devices (Only Applicable for Professionals) Name of Device Date of Treatment Date format: 12/05/22 Reaction Symptoms When was reaction first apparent? Date format: 12/05/22 When was it reported? Date format: 12/05/22 TREATMENT INFORMATION (Product Specific) Treatment Provided * Date of Treatment * Date format: 12/05/22 Reaction Symptoms * When was reaction first apparent? * Date format: 12/05/22 When was it reported? * Date format: 12/05/22 Were photos taken? * No If Yes, By Who?If Yes, By Who? Upload Photos Upload/ Drag & Drop Photo Here Choose file Maximum upload size: 516MB What instructions were given to the patient when the reaction was reported? (Only Applicable for Professionals) Please recount the steps of the treatment with specific product names Cleanse * Treat/Exfoliate * Areas Treated * Time Left on Skin * How Neutralized * Time Neutralized * Skin Response at the End of Neutralization (e.g. Redness, Irritation, Discomfort or other responses) * Extractions Performed? * No Yes Hydrating Mask Areas Treated Time Left on Skin Skin Response at the End of Masque Products Applied Immediately Post-Treatment Products Applied by User Post-Treatment: Next Days If you are human, leave this field blank. Submit
