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Rx Incident Report Form Mobile App

Pharmacy’s must follow strict guidelines in regards to incidents, especially once involving mediations both prescribed (Rx) and over the counter (OCR). Use the Rx Incident Report Form mobile app to document prescription incidences using a hand held mobile device. The app records pharmacy information, patient information, incident information and a detailed description of the incident.

  • Lendlease
  • The Cooperative
  • PG&E
  • Red Bull
  • Mirvac

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Take a peek inside the Rx Incident Report Form Mobile App

Included Features

Our App Builder gives you the power to easily add and remove the ones you want. {{controller.show_all ? 'See included features.' : 'See more features.'}}

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Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico textbox

    Pharmacy Name

  • Ico textbox

    Phone

  • Ico statictext

    New Static Text

  • Ico multiline

    Pharmacy Address

  • Ico textbox

    Patient Name

  • Ico dropdown

    Gender

  • Ico date

    Date of Birth

  • Ico textbox

    Phone No.

  • Ico multiline

    Address

  • Ico textbox

    Name of Parent/Guardian (if minor)

  • Ico date

    Date of Incident

  • Ico textbox

    Incident Reported

  • Ico textbox

    RX No.

  • Ico checkbox

    New

  • Ico checkbox

    Refill

  • Ico dropdown

    Prescription Scanned?

  • Ico textbox

    Prescribed Drug/Strength

  • Ico textbox

    Directions

  • Ico textbox

    Quantity Prescribed

  • Ico textbox

    Quantity Ingested/Applied

  • Ico textbox

    Quantity Dispensed

  • Ico textbox

    Quantity Returned

  • Ico textbox

    Verifying/Filling Pharmacist Name

  • Ico textbox

    Name

  • Ico textbox

    License No.

  • Ico multiline

    Other Personnel Involved and License/Registration Number:

  • Ico multiline

    Pharmacist Description of Incident:

  • Ico checkbox

    1) Patient Allegedly received wrong drug

  • ...and More!

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