Nose Pad Skin Irritation Report Form
Please use this form to report any skin irritation you have experienced from nose pads. Your feedback helps us improve product comfort and safety.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number (optional)
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Irritation Incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Which product were you wearing when the irritation occurred?
*
Please Select
Titanium Nose Pads
Silicone Nose Pads
PVC Nose Pads
Other
Describe the skin irritation you experienced
*
How severe was the irritation?
*
Mild (slight redness or discomfort)
Moderate (persistent redness, swelling, or itching)
Severe (blistering, open sores, or significant pain)
Where did the irritation occur?
*
Left side of nose
Right side of nose
Both sides
Other area
Did you seek any treatment for the irritation?
*
No treatment needed
Self-treated at home
Consulted a healthcare professional
Upload a photo (optional)
Upload a File
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Additional comments or suggestions
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