Feedback and incident form

In the event of a health emergency please contact 000

Use this form to provide feedback or report a clinical incident in relation to pilot services delivered as part of the Queensland Community Pharmacy Chronic Conditions Management Pilot.

From 1 July 2025, most services previously delivered under the Scope of Practice and Hormonal Contraception pilots have transitioned to permanent community pharmacy services. These services are no longer part of a pilot.

Do not use this form to provide feedback about non-pilot services. Feedback about other pharmacy services (non-pilot services) can be provided directly to the pharmacy or to agencies that review complaints about health services, such as the Queensland Ombudsman or the Office of the Health Ombudsman.

If you are unsure whether the service you received is part of the Pilot, you may wish to contact the pharmacy before submitting this form. You can also check with the Pilot Coordination Team at qld-pharmacyscopepilot@health.qld.gov.au.

Privacy

Personal information collected by the Department of Health is handled in accordance with the Information Privacy Act 2009. The Department of Health is collecting personal information in order to appropriately inform implementation activities and quality and safety management and reporting for the Queensland community pharmacy pilots.

All personal information will be securely stored and only accessible by authorised employees of Queensland Health (or its agents). Your personal information will not be disclosed to other third parties without consent, unless disclosure is authorised or required by or under law.

For information about how the Department of Health protects your personal information, or to learn about your right to access your own personal information, please see our website at www.health.qld.gov.au

Required fields are marked with an asterisk (*).

Do you want to remain anonymous? *

Please note, clinical incidents cannot be reported anonymously. Identifiable details must be included to enable appropriate action to occur in response to a clinical incident. By providing this information, you consent to the information being used to appropriately respond to reported clinical incidents.

Selecting to remain anonymous may limit our ability to comprehensively investigate your feedback, however all feedback will be recorded and reviewed as appropriate.
Would you like to *
Are you a *
Do you have a preferred method of contact? *
This can be located on your referral documentation and consultation summary.
Do you have the patient’s consent to report this incident and disclose their personal details? These details may include their encounter ID and specific incident details.
This can be located on the referral documentation and consultation summary
Please include as much detail as possible and explain what action you would like the pharmacy to take. If possible, the following information should be provided:
  • describe what occurred
  • explain the order in which things happened
  • include dates where possible
  • list any phone calls, letters or meetings.
Please include as much detail as possible about the suggestion for improvement. This may include clearly describing the proposed improvement or providing examples as to how your suggestion may be implemented.
Please include as much detail as possible relating to your feedback and explain what action you would like the pharmacy to take. If possible, the following information should be provided:
  • describe what occurred
  • explain the order in which things happened
  • include dates where possible
  • list any phone calls, letters or meetings.
Please include the pharmacy name and pharmacy address.
Please list the name and address of the participating pharmacy (if applicable):
Has this feedback been shared directly with the pharmacy? *
Has this feedback been raised directly with the pharmacy or with any other organisation? * For example: 13 HEALTH, Office of the Health Ombudsman.
Has this incident been raised directly with the pharmacy or with any other organisation? For example: 13 HEALTH, Office of the Health Ombudsman.
Are you willing to be contacted by Queensland Health if further information relating to your feedback is required? *
Would you like a response in relation to the feedback provided?

Last updated: 7 July 2025