Incident Reporting Form

This form is used to document any clinical, operational, health & safety, or behavioural incident that occurs within the premises of Haus of Ästhetik Ltd., including near-misses.

Accurate and timely completion supports compliance with CQC and HSE standards, ensures patient safety, promotes transparency, and informs continuous quality improvement.

Please complete all relevant sections with clear, factual detail. This form includes the following:

• Type, date, and time of incident

• Reporting member’s details

• Patient(s) or witness(es) involved

• Objective description of the incident

• Immediate action taken

• Follow-up intervention or escalation

• Option to upload photographic evidence (if applicable)

All reports must be submitted on the day of the incident or within 24 hours.

Completed forms will be reviewed by the Clinical Lead or Managing Director and stored securely in accordance with GDPR and internal governance protocols.

Type Of Incident: *

Date Of Incident: *

Time Of Incident: *

Reporting Member's Name: *

Patient / Witnesses If Any:

Write Up What Happened: *

Instructions for Incident Description: Provide a clear, factual account of the incident. Include what happened, where, when, and who was involved. Describe any contributing factors or sequence of events. Avoid opinions or assumptions—stick to what was observed or known.

This field is required.

Action Taken At The Time: *

Follow-Up Action / Intervention: *

Picture of Concern or Near Miss:

The max file size is 10MB.

Please upload a file before submitting.

Incident Reporting Form:

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