{"id":7231,"date":"2024-12-05T11:21:25","date_gmt":"2024-12-05T10:21:25","guid":{"rendered":"https:\/\/www.panougeparis.com\/?page_id=7231"},"modified":"2024-12-05T11:52:48","modified_gmt":"2024-12-05T10:52:48","slug":"adverse-event-contact-form","status":"publish","type":"page","link":"https:\/\/www.panougeparis.com\/fr\/adverse-event-contact-form\/","title":{"rendered":"Adverse Event Contact Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"7231\" class=\"elementor elementor-7231\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-d3725a5 elementor-section-height-min-height elementor-section-boxed elementor-section-height-default elementor-section-items-middle\" data-id=\"d3725a5\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t\t<div class=\"elementor-background-overlay\"><\/div>\n\t\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-498df1b\" data-id=\"498df1b\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-549d5b9 elementor-widget elementor-widget-spacer\" data-id=\"549d5b9\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-6263d2f elementor-widget elementor-widget-heading\" data-id=\"6263d2f\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-xl\">ADVERSE EVENT CONTACT FORM<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-0a5c227 elementor-widget-divider--view-line elementor-widget elementor-widget-divider\" data-id=\"0a5c227\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"divider.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-divider\">\n\t\t\t<span class=\"elementor-divider-separator\">\n\t\t\t\t\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-4525605 elementor-widget elementor-widget-heading\" data-id=\"4525605\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h5 class=\"elementor-heading-title elementor-size-default\">If you have experienced an adverse event after using one of our products, please complete the form below. <br><br>Be assured that all provided data are confidential and will be processed as soon as possible.<br><br>Once the form is completed, you will receive a submission  confirmation and copy  at the email address provided.<\/h5>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-02c37e9 elementor-widget elementor-widget-spacer\" data-id=\"02c37e9\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-75f46b1 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"75f46b1\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-d6f5d38\" data-id=\"d6f5d38\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-3a7bf2a elementor-button-align-stretch elementor-widget elementor-widget-form\" data-id=\"3a7bf2a\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;step_next_label&quot;:&quot;Next&quot;,&quot;step_previous_label&quot;:&quot;Previous&quot;,&quot;button_width&quot;:&quot;100&quot;,&quot;step_type&quot;:&quot;number_text&quot;,&quot;step_icon_shape&quot;:&quot;circle&quot;}\" data-widget_type=\"form.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<form class=\"elementor-form\" method=\"post\" name=\"Adverse Event Form \/ JACQUES FATH\" aria-label=\"Adverse Event Form \/ JACQUES FATH\" novalidate=\"\">\n\t\t\t<input type=\"hidden\" name=\"post_id\" value=\"7231\"\/>\n\t\t\t<input type=\"hidden\" name=\"form_id\" value=\"3a7bf2a\"\/>\n\t\t\t<input type=\"hidden\" name=\"referer_title\" value=\"Adverse Event Contact Form | Panouge Paris\" \/>\n\n\t\t\t\t\t\t\t<input type=\"hidden\" name=\"queried_id\" value=\"7231\"\/>\n\t\t\t\n\t\t\t<div class=\"elementor-form-fields-wrapper elementor-labels-above\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-name elementor-col-33 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-name\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tLast Name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[name]\" id=\"form-field-name\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Last Name\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_200b1c0 elementor-col-33 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_200b1c0\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tFirst Name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_200b1c0]\" id=\"form-field-field_200b1c0\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"First Name\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-number elementor-field-group elementor-column elementor-field-group-field_9f3cb18 elementor-col-33 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_9f3cb18\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAge\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t<input type=\"number\" name=\"form_fields[field_9f3cb18]\" id=\"form-field-field_9f3cb18\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Age or birth year\" required=\"required\" min=\"\" max=\"\" >\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_38a20e7 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_38a20e7\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCountry of Residence\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_38a20e7]\" id=\"form-field-field_38a20e7\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Country of Residence\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_c2fc9b9 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_c2fc9b9\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCity of Residence\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_c2fc9b9]\" id=\"form-field-field_c2fc9b9\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"City of Residence\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-tel elementor-field-group elementor-column elementor-field-group-field_315dbda elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_315dbda\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPhone Number\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input size=\"1\" type=\"tel\" name=\"form_fields[field_315dbda]\" id=\"form-field-field_315dbda\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Phone Number\" required=\"required\" pattern=\"[0-9()#&amp;+*-=.]+\" title=\"Seuls les caract\u00e8res de num\u00e9ros de t\u00e9l\u00e9phone (#, -, *, etc.) sont accept\u00e9s.\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-email elementor-field-group elementor-column elementor-field-group-field_7fc2d09 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7fc2d09\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEmail Address\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"email\" name=\"form_fields[field_7fc2d09]\" id=\"form-field-field_7fc2d09\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Email Address\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_3549153 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_3549153\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tGender\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_3549153]\" id=\"form-field-field_3549153\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Male\">Male<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Female\">Female<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Prefer not to specify\">Prefer not to specify<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_4c852e4 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_4c852e4\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tProduct Name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_4c852e4]\" id=\"form-field-field_4c852e4\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Product Name\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_696e89b elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_696e89b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tProduct Size\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_696e89b]\" id=\"form-field-field_696e89b\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Product Size (ml \/ fl oz or g \/ oz)\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_db4a41f elementor-col-60\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_db4a41f\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tBatch Number\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_db4a41f]\" id=\"form-field-field_db4a41f\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"4 characters that begins with a number followed by a letter, found on the bottom of the packaging\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_37a7a03 elementor-col-60 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_37a7a03\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tWhere did you purchase this product?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_37a7a03]\" id=\"form-field-field_37a7a03\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Name of boutique or retailer you purchased (ex: Panouge Paris Online Boutique, etc.)\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-upload elementor-field-group elementor-column elementor-field-group-field_6686d10 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_6686d10\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tProduct Images (Please upload at least one photo of the concerned product)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input type=\"file\" name=\"form_fields[field_6686d10]\" id=\"form-field-field_6686d10\" class=\"elementor-field elementor-size-sm  elementor-upload-field\" required=\"required\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-field_1def1e5 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_1def1e5\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDate of the first use with this suspected product:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[field_1def1e5]\" id=\"form-field-field_1def1e5\" class=\"elementor-field elementor-size-sm  elementor-field-textual elementor-date-field\" placeholder=\"yyyy\/mm\/dd\" required=\"required\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\" min=\"1999-01-01\" max=\"2040-01-01\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-field_8212374 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_8212374\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDate of the last use with this suspected product:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[field_8212374]\" id=\"form-field-field_8212374\" class=\"elementor-field elementor-size-sm  elementor-field-textual elementor-date-field\" placeholder=\"yyyy\/mm\/dd\" required=\"required\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\" min=\"1999-01-01\" max=\"2040-01-01\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_67529fb elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_67529fb\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo you usually buy this product?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_67529fb]\" id=\"form-field-field_67529fb\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-field_b988c5e elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_b988c5e\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDate of adverse event:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[field_b988c5e]\" id=\"form-field-field_b988c5e\" class=\"elementor-field elementor-size-sm  elementor-field-textual elementor-date-field\" placeholder=\"yyyy\/mm\/dd\" required=\"required\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\" min=\"1999-01-01\" max=\"2040-01-01\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_b86954b elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_b86954b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDescribe event \/ observed reaction:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_b86954b]\" id=\"form-field-field_b86954b\" rows=\"4\" placeholder=\"Please describe the event \/ observed reaction, along with any additional details you can provide.\" required=\"required\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_cd5f72b elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_cd5f72b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tApplication area:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Neck\" id=\"form-field-field_cd5f72b-0\" name=\"form_fields[field_cd5f72b][]\"> <label for=\"form-field-field_cd5f72b-0\">Neck<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Chest\" id=\"form-field-field_cd5f72b-1\" name=\"form_fields[field_cd5f72b][]\"> <label for=\"form-field-field_cd5f72b-1\">Chest<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Wrists\" id=\"form-field-field_cd5f72b-2\" name=\"form_fields[field_cd5f72b][]\"> <label for=\"form-field-field_cd5f72b-2\">Wrists<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Other\" id=\"form-field-field_cd5f72b-3\" name=\"form_fields[field_cd5f72b][]\"> <label for=\"form-field-field_cd5f72b-3\">Other<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_2929dfe elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_2929dfe\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tThe reaction was observed:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_2929dfe]\" id=\"form-field-field_2929dfe\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Where I applied the product\">Where I applied the product<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"On a different zone\">On a different zone<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_eb9eac1 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_eb9eac1\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDid you apply another cosmetic product in the same area during the day?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_eb9eac1]\" id=\"form-field-field_eb9eac1\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_a7d9a50 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a7d9a50\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDid you expose the area to sunlight after the use of the product?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_a7d9a50]\" id=\"form-field-field_a7d9a50\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">Yes<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_59ed8e8 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_59ed8e8\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tRelevant test \/ Laboratory data: \t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_59ed8e8]\" id=\"form-field-field_59ed8e8\" rows=\"4\" placeholder=\"Please provide any relevant test or laboratory data.\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-recaptcha_v3 elementor-field-group elementor-column elementor-field-group-field_a65e4fd elementor-col-100 recaptcha_v3-inline\">\n\t\t\t\t\t<div class=\"elementor-field\" id=\"form-field-field_a65e4fd\"><div class=\"elementor-g-recaptcha\" data-sitekey=\"6LcDD0YnAAAAAAyxk9rACvzYvbwYrXhZawwtxlUQ\" data-type=\"v3\" data-action=\"Form\" data-badge=\"inline\" data-size=\"invisible\"><\/div><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-group elementor-column elementor-field-type-submit elementor-col-100 e-form__buttons\">\n\t\t\t\t\t<button class=\"elementor-button elementor-size-sm\" type=\"submit\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Send<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/form>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-164ddf7 elementor-widget elementor-widget-spacer\" data-id=\"164ddf7\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-97363fc elementor-widget-divider--view-line elementor-widget elementor-widget-divider\" data-id=\"97363fc\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"divider.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-divider\">\n\t\t\t<span class=\"elementor-divider-separator\">\n\t\t\t\t\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-535bfd6 elementor-widget elementor-widget-heading\" data-id=\"535bfd6\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Need Assistance?<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-2275390 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"2275390\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-8c365e9\" data-id=\"8c365e9\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-d0f506f\" data-id=\"d0f506f\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-240ceef elementor-widget elementor-widget-text-editor\" data-id=\"240ceef\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>Panouge Paris Client Service Advisors are available by phone Monday through Friday, from 10am to 5pm CET at:\u00a0<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-55257f4 elementor-widget elementor-widget-text-editor\" data-id=\"55257f4\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>+33 1 47 20 56 77<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-76ca756\" data-id=\"76ca756\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-c45162c elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"c45162c\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-3c850fd\" data-id=\"3c850fd\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-0328f71 elementor-widget elementor-widget-spacer\" data-id=\"0328f71\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>ADVERSE EVENT CONTACT FORM If you have experienced an adverse event after using one of our products, please complete the form below. Be assured that all provided data are confidential and will be processed as soon as possible. Once the form is completed, you will receive a submission confirmation and copy at the email address [&hellip;]<\/p>\n","protected":false},"author":11,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-7231","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v28.0 (Yoast SEO v28.0) - https:\/\/yoast.com\/product\/yoast-seo-premium-wordpress\/ -->\n<title>Adverse Event Contact Form | Panouge Paris<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.panougeparis.com\/fr\/adverse-event-contact-form\/\" \/>\n<meta property=\"og:locale\" content=\"fr_FR\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Adverse Event Contact Form\" \/>\n<meta property=\"og:description\" content=\"ADVERSE EVENT CONTACT FORM If you have experienced an adverse event after using one of our products, please complete the form below. Be assured that all provided data are confidential and will be processed as soon as possible. Once the form is completed, you will receive a submission confirmation and copy at the email address [&hellip;]\" \/>\n<meta property=\"og:url\" content=\"https:\/\/www.panougeparis.com\/fr\/adverse-event-contact-form\/\" \/>\n<meta property=\"og:site_name\" content=\"Panouge Paris\" \/>\n<meta property=\"article:publisher\" content=\"https:\/\/www.facebook.com\/Panouge-152570516387\" \/>\n<meta property=\"article:modified_time\" content=\"2024-12-05T10:52:48+00:00\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:label1\" content=\"Dur\u00e9e de lecture estim\u00e9e\" \/>\n\t<meta name=\"twitter:data1\" content=\"1 minute\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\\\/\\\/schema.org\",\"@graph\":[{\"@type\":\"WebPage\",\"@id\":\"https:\\\/\\\/www.panougeparis.com\\\/adverse-event-contact-form\\\/\",\"url\":\"https:\\\/\\\/www.panougeparis.com\\\/adverse-event-contact-form\\\/\",\"name\":\"Adverse Event Contact Form | Panouge Paris\",\"isPartOf\":{\"@id\":\"https:\\\/\\\/www.panougeparis.com\\\/#website\"},\"datePublished\":\"2024-12-05T10:21:25+00:00\",\"dateModified\":\"2024-12-05T10:52:48+00:00\",\"breadcrumb\":{\"@id\":\"https:\\\/\\\/www.panougeparis.com\\\/adverse-event-contact-form\\\/#breadcrumb\"},\"inLanguage\":\"fr-FR\",\"potentialAction\":[{\"@type\":\"ReadAction\",\"target\":[\"https:\\\/\\\/www.panougeparis.com\\\/adverse-event-contact-form\\\/\"]}]},{\"@type\":\"BreadcrumbList\",\"@id\":\"https:\\\/\\\/www.panougeparis.com\\\/adverse-event-contact-form\\\/#breadcrumb\",\"itemListElement\":[{\"@type\":\"ListItem\",\"position\":1,\"name\":\"Home\",\"item\":\"https:\\\/\\\/www.panougeparis.com\\\/\"},{\"@type\":\"ListItem\",\"position\":2,\"name\":\"Adverse Event Contact Form\"}]},{\"@type\":\"WebSite\",\"@id\":\"https:\\\/\\\/www.panougeparis.com\\\/#website\",\"url\":\"https:\\\/\\\/www.panougeparis.com\\\/\",\"name\":\"Panouge Paris\",\"description\":\"Official Store\",\"publisher\":{\"@id\":\"https:\\\/\\\/www.panougeparis.com\\\/#organization\"},\"potentialAction\":[{\"@type\":\"SearchAction\",\"target\":{\"@type\":\"EntryPoint\",\"urlTemplate\":\"https:\\\/\\\/www.panougeparis.com\\\/?s={search_term_string}\"},\"query-input\":{\"@type\":\"PropertyValueSpecification\",\"valueRequired\":true,\"valueName\":\"search_term_string\"}}],\"inLanguage\":\"fr-FR\"},{\"@type\":\"Organization\",\"@id\":\"https:\\\/\\\/www.panougeparis.com\\\/#organization\",\"name\":\"Panouge Paris - Official Store\",\"url\":\"https:\\\/\\\/www.panougeparis.com\\\/\",\"logo\":{\"@type\":\"ImageObject\",\"inLanguage\":\"fr-FR\",\"@id\":\"https:\\\/\\\/www.panougeparis.com\\\/#\\\/schema\\\/logo\\\/image\\\/\",\"url\":\"https:\\\/\\\/www.panougeparis.com\\\/wp-content\\\/uploads\\\/2021\\\/03\\\/logo-panouge-paris-scaled-min.jpg\",\"contentUrl\":\"https:\\\/\\\/www.panougeparis.com\\\/wp-content\\\/uploads\\\/2021\\\/03\\\/logo-panouge-paris-scaled-min.jpg\",\"width\":2560,\"height\":1600,\"caption\":\"Panouge Paris - Official Store\"},\"image\":{\"@id\":\"https:\\\/\\\/www.panougeparis.com\\\/#\\\/schema\\\/logo\\\/image\\\/\"},\"sameAs\":[\"https:\\\/\\\/www.facebook.com\\\/Panouge-152570516387\",\"https:\\\/\\\/www.instagram.com\\\/panougeparis\\\/?hl=fr\"]}]}<\/script>\n<!-- \/ Yoast SEO Premium plugin. -->","yoast_head_json":{"title":"Adverse Event Contact Form | Panouge Paris","robots":{"index":"index","follow":"follow","max-snippet":"max-snippet:-1","max-image-preview":"max-image-preview:large","max-video-preview":"max-video-preview:-1"},"canonical":"https:\/\/www.panougeparis.com\/fr\/adverse-event-contact-form\/","og_locale":"fr_FR","og_type":"article","og_title":"Adverse Event Contact Form","og_description":"ADVERSE EVENT CONTACT FORM If you have experienced an adverse event after using one of our products, please complete the form below. 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