Horizon Beauty Group LLC – Cosmetics Adverse Events Reporting

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1Consumer Details

2Event Information

3Product Information

4Review and Confirm

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Notification Email (Owner)

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Fetched Email Addresses

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Company Name

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User ID

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CD Record Number

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Dropdown

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Product name text

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Multi Product name text

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Customers Age

Consumer Information

Please enter the contact information for the person who experienced the adverse event.

Consumer Name*

Consumer Email*

Consumer Phone*

Consumer Address 1

Consumer Address 2

Consumer City*

Consumer State*

Consumer Postal Code

Consumer Date of Birth*

Please enter the date in MM/DD/YYYY format.

Age

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Consumer Date of Birth*

Please enter the date in MM/DD/YYYY format.

Sex

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Gender

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Please specify gender*

Include as many details as possible

If other please specify*

Include as many details as possible

Weight

Weight Unit

Lbs

Race

Ethnicity

Skin Type

Skin Reactivity

Person reporting this information is different than the consumer above

Person reporting this information is different than the consumer above.

Reporter Information

Please enter the contact information of the person reporting this adverse event.

Same as Consumer

Use consumer address information.

Are you a health professional?

Yes

Also sent the report to FDA?

Yes

Unknown

Reporter Name*

Reporter Email*

Reporter Phone*

Reporter Occupation

Reporter Address 1

Reporter Address 2

Reporter City*

Reporter State*

Reporter Postal Code

Product Information

Brand Name*

Product Name*

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Brand Name*

Product Name*

Have you used any other product(s) of this brand?

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Manufacturer

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Packer

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Distributor

Date of first use?

Please enter the date in MM/DD/YYYY format.

Date of last use?

Please enter the date in MM/DD/YYYY format.

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Date of first use?

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Date of last use?

Do you still have the product?*

Yes

Do you have a picture of the product?

Yes

Front and Back of Label*

Drop files here or

Accepted file types: jpg, jpeg, png, doc, Max. file size: 256 MB.

Is this product labeled for single use?

Yes

Expiration Date

Please enter the date in MM/YYYY format.

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Expiration Date

Product Identifier

Product Batch No / Lot Code

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Serial Number

Event reappeared after reintroduction?

Yes

Does not apply

Please add details of the area of the use?

Have you used any other cosmetic products?

Have you changed your skincare routine or skincare products in recent times?

Retailer Information

Retailer Name

Retailer Address 1

Retailer Address 2

Retailer City

Retailer State

Retailer Postal Code

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Retailer Website

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Retailer Phone

Reported Symptom	Intensity	Time of onset after applying	Duration of the issue	Was there spontaneous resolution after discontinuation?	Actions

There are no Entries.

Consumer Information

Reporter Information

Adverse Event Information

Product Information

Retailer Information

Review And Confirm

Consumer Information

Reporter Information

Event Information

Product Information

Jones NY Rose and Musk Body Mist 8.4oz
Jones NY Japanese Cherry EDP 100ml
Jones NY Violet Blossom and Sandalwood Body Mist 8oz
Candies Charm 100ml EDP
Jones New York Peony and Amberwood 100ml EDP
Badgley Mischka Body Mist- POPPY
Badgley Mischka Body Mist - AVA
Tahari Men Lemongrass Deodorizing Body Spray 6 oz 170g
Candies Pink Amber Fragrance Mist 8.4 Oz
JORDACHE QUINN 3.4oz Spray
JORDACHE DREAMS OF PINK BODY MIST
Candies Man EDT 100ml
JORDACHE BILLIE 3.4oz Spray
Tahari Desert Sun Body Mist
Candies Holiday Mists-Sugar Cookie
JORDACHE MEN Authentic Body Spray-Blue
Jones NY Gardenia and Oud Body Mist 8.4oz
Tahari Men Aqua Wave Deodorizing Spray 6oz 170g
Jones NY Rose and Musk 100ml EDP
Candies Citrus Sorbet Body Mist
JORDACHE FRANKIE 3.4oz Spray
Tahari Midnight Orchid 3.4oz Spray
Tahari Men Black Deodorizing Spray 6oz 170g
Candies Berrylicious 3.3oz Spray
Jones NY Peony and Amberwood Body Mist 8oz
Candies Berry Musk Body Mist
Tahari Midnight Orchid Body Spray
Tahari Desert Sun 3.4oz Spray
Tahari French Kiss Body Spray
JORDACHE BODY MIST PURPLE JASMINE NIGHTS
JORDACHE MEN EDT INDIGO
BADGLEY MISCHKA CHATEAU VIZCAYA EDP 100ML TESTER
Candies Holiday Mists-Peppermint
Jones New York Violet Blossom and Sandalwood 100ml EDP
JORDACHE BODY MIST YELLOW BEACH RUN
Candies Woman EDP 100ml
Candies Black 3.3oz Spray
JORDACHE MEN EDT STONE
JORDACHE BODY MIST TIE DYE BLUE SURF
BADGLEY MISCHKA CAP D ANTIBES EDP 100ML TESTER
Tahari Midnight Orchid Body Butter 354ml
Tahari Men Black EDT Spray 3.4 oz 100ml
Tahari French Kiss Body Scrub 354ml
Tahari Midnight Orchid Body Scrub
Badgley Mischka Audrey 100ml EDP Boxed
Tahari Mens Aqua Wave EDT Spray 3.4ox 100ml
Badgley Mischka Ava Boxed
Tahari Mens Red Musk EDT Spray 3.4oz 100ml
Candies Malibu Crush 3.4oz Spray
Badgley Mischka Body Mist- AUDREY
Tahari Men Red Musk Deodorizing Body Spray 6 oz 170 g
BADGLEY MISCHKA CHATEAU VIZCAYA EDP 100ML
Jones NY Rare Vanilla Blossom EDP 100ml
Candies Red 3.4oz Spray
Betsey Johnson 236ml 8 Fl. oz. Body Mist
CANDIEs MIST VANILA AMBER 8.4oz
Jones NY Gardenia and Oud 100ml EDP
BADGLEY MISCHKA CAP D ANTIBES EDP 100ML
JORDACHE MEN Classic Body Spray-Azure
JORDACHE MEN Signature Body Spray-Black
CANDIES MIST PINK APPLE-8.4 OZ
Tahari French Kiss 3.4oz Spray
Tahari French Kiss Body Butter 354ml
Badgley Mischka Poppy Boxed
Tahari Mens Lemongrass EDT Spray 3.4oz 100ml
Sweet Treats-Cherrylicious 100ml EDP
Tahari Prive Bordeaux Elixir Men 100ml EDP
Candies MINT CHOCOLATE CHIP Eyeliner
Candies GELATO Eye Palette
Tahari Prive Cobalt Smoke Men 100ml EDP
Tahari Leather Oud 100ml EDT
Candies ITALIAN ICE Lipgloss Trio Set
Candies MINT CHOCOLATE CHIP Mascara
Candies S.MORES Contour Palette-Chocolate Highlight
Tahari Pistachio Cloud 3.4oz Spray
Sweet Treats-Sugarlicious 100ml EDP
Sweet Treats-Vanillalicious 100ml EDP
Candies ICE CREAM Eye Palette
Betsey Johnson 100 ml edp spray
Betsey Johnson 50 ml edp spray
BADGLEY MISCHKA CAP D ANTIBES EDP 2ML VIAL
BADGLEY MISCHKA CHATEAU VIZCAYA EDP 2ML VIAL
BADGLEY MISCHKA CAP D ANTIBES EDP 200ML TUBE
Betsey Johnson 30 ml edp spray
BADGLEY MISCHKA CHATEAU VIZCAYA EDP 200ML TUBE
Tahari Men 3x30ml-Explore Collection (Black)
Tahari Men 3x30ml-Explore Collection
Tahari Men 3x30ml-Explore Collection (Leather Oud)
Amore a Positano EDP 100ml
Amore a Positano Hair and body Mist
Sole A Sorrento Hair and Body Mist
Sole A Sorrento EDP 100ml
TimeDefy Face Serum
TimeFiller Face Moisturizer
EyeRevive Eye Cream
NeckLift Neck Treatment