SuperPharmacyPlus Complaint and Incident Form

NDIS Complaint & Incident Report
SuperPharmacyPlus is a community Pharmacy focusing on professional services. At SuperPharmacyPlus we believe in the dignity and quality of care for each of our clients. We are aligned with the NDIS Quality and Safeguards Commission in our desire to promote safe, quality services and resolve participant incidents with efficiency and care.

Please complete the following report form to enable us to manage your incident.

If you require assistance in completing this form, our staff are available to assist on 07 3355 3052 or alternatively at ndis@superpharmacyplus.com.au

Shoud you require further assistance or advocacy with respect to the following incident, SuperPharmacyPlus also supports the rights of all participants to seek further support directly from the NDIS Quality and Safeguards Commission as required.
Further information on the support available can be found here.
Report Type*

IncidentComplaintFeedbackOther
Participant's Name?*

First NameLast Name
NDIS Participant Number
Participant's Address?*

Street Address

Street Address Line 2

CityState / Territory

Post Code
Phone Number
Email Address?*
Person preparing this report
*If other than the participant
Date and Time of Incident?*

MonthDayYearHourMinutesAM/PM Option
Place of Incident
Nature of Incident*
Specific Action Taken
Follow-up required
Feedback
Attachments to Upload

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