Adverse Reaction Form

NOTE: This form is to be used only in cases of serious health issues arising from the use of the product.  All submissions will be investigated fully and reported to government regulatory officials.

*Denotes Required Field

Name: *
  
Are you a physician or patient? *
  
Address: *
  
Address:
  
City: *
  
State: *
  
Zip Code: *
  
Telephone: *
  
Fax:
  
Email: *
  
We are required to follow-up. Please advise us on how best to communicate with you: *
  
Best Time to Contact: *
  
Product Name: *
  
Lot Number:
  
Event Date: *
     mm/dd/yy
Event Time: *
  
Description of Reaction: *
Was medical intervention required? *
  
If yes, please provide the facility or physician information:
 
"I attest and affirm that the statements made are accurate and verifiable."

Our Products

Advanced Topical Gel

Advanced Topical Gel

Relieves pain associated with:

  • Repetitive Stress
  • Arthritis
  • Joint Pain

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Advanced Oral Spray

Advanced Oral Spray

Relieves pain associated with:

  • Lower back pain
  • Migraines
  • Neck aches
  • Shoulder pain
  • Cramps
  • Neuralgia

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