Service Recovery & Occurrence Report
Customer Name
*
First Name
Last Name
Date of Occurrence
*
-
Month
-
Day
Year
Date
Occurrence Location
*
Please Select
North
South
White Sulphur Springs
Alleghany
Union
Western Greenbrier Pharmacy
Customer Phone
*
Please enter a valid phone number.
Date of Birth
-
Month
-
Day
Year
Date
Filling Pharmacist
RX Number
Filling Tech
Type of Occurrence
Please Select
Adverse Event
Service Recovery Opportunity
Communication Issue
Delay of Service/Timeliness
Complaint
Billing/Insurance Issue
Delivery or Mail Service
Repairs/Maintenance/Physical Plant
Patient/Employee Injury
Medication Error
Customer Received Someone Else's Medication
Other
Red, White, & Blue Medicare Number (if applicable)
Complete description of occurrence, service recovery opportunity or complaint
Response or action taken by staff, including all correspondence
Specify any additional action or follow-up required for problem resolution
What steps could we follow to ensure quality in the future?
Person Completing Form
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