REBIOME – TREATMENT REACTION QUESTIONNAIRE REBIOME – TREATMENT REACTION QUESTIONNAIRE REBIOME – TREATMENT REACTION QUESTIONNAIRE Individual reporting Individual Reporting Reaction * Dato * Reporter Email * Phone * Clinic Name * Client information Individual who Experienced Reaction * Skin Type * Skin Concerns Being Treated * Date of Last Skin Treatment Results of Last Skin Treatment Does the patient use any topical prescriptions * Yes No Did the patient use any home skincare devices * Yes No Does the patient have an allergy * Did the patient use ReSurface? Yes No - if yes does the patient have an allergy to pineapple?- if yes does the patient have an allergy to pineapple? Treatment Information Treatment Provided * Date of Treatment * Reaction Symptoms * When was reaction first apparent * When was it reported * Were photos taken * Yes No Fil upload Drop a file here or click to upload Choose File Maximum upload size: 516MB What instructions were given to the patient when the reaction was reported (only applicable for professionals) * Products used during treatment * Areas Treated * Time left on skin * Skin response at the end of treatment (e.g., redness, irritation, discomfort, or other responses) * Products applied immediately post-treatment * Product Information Product name * LOT no. * Expiry date * If you are human, leave this field blank. Submit
