Incident Report Form

Ultraformer MPT Patient Consent Form

Name(Required)

INCIDENT DETAILS

Time of Incident
:

CLIENT DETAILS

INCIDENT TYPE

Incident Type(Required)

INCIDENT DESCRIPTION

TREATMENT INVOLVED

CLIENT CONDITION

Severity

IMMEDIATE ACTION TAKEN

Immediate Actions

MEDICAL FOLLOW-UP

GP / Medical Practitioner Contacted
Hospital Attendance
Follow-Up Required

PHOTOGRAPHIC RECORD

Photographic Record

ROOT CAUSE ANALYSIS

CORRECTIVE ACTIONS

NOTIFICATION REQUIREMENTS

Notifications Completed

REVIEW & CLOSE OUT

Further Action Required

SIGNATURES

Clear Signature
Clear Signature
Clear Signature