Patient Incident/Complaint Form

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This patient complaint/incident form is used to document the following BY PATIENTS: Any type of accident or injury reported by the patient related to care or treatment, patient-provider conflicts, general complaints, etc.

Name *

Address: *

Phone Number *

Date of Incident:

YYYY

Time:

Time

Type of Incident: *

Pharmacy

Scheduling

Phones

Transportation

Staff Behavior

Facilities

Patient Injury

Patient to Patient Incident

Other:

If there was an injury, please describe

Description of Incident: *

Location: *

Arapahoe Clinic

12th Street Clinic

Ethete Clinic

White Buffalo

Witnesses involved (if any): *

Recommendations for staff/follow up: *

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