Incident and Adverse Reaction Report Form
Structured form for documenting allergic reactions, burns, injuries and other incidents during or after treatment. Essential for insurance claims.
Use this when
- Allergic reactions
- Burns or scalds
- Chemical incidents
- Client injury
- Insurance claims
Free — we only ask for your email on first use.
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Incident / Adverse Reaction Report Form
Business name: _______________________________________________
Section A - Practitioner Details
| Field | Details |
|---|---|
| Practitioner name | |
| Business name | |
| Contact number | |
| Insurance provider | |
| Policy number |
Section B - Client Details
| Field | Details |
|---|---|
| Client name | |
| Contact number | |
| Date of birth (optional - useful for insurance) |
Section C - Treatment Details
| Field | Details |
|---|---|
| Date of treatment | |
| Time treatment started | |
| Time treatment ended | |
| Treatment type (e.g. hair colour, lash extensions, waxing, facial, injectables) |
Products used:
| Product brand | Product name | Batch number (where available) |
|---|---|---|
Equipment used:
| Question | Answer |
|---|---|
| Was a patch test carried out? | Yes / No |
| If yes, date of patch test | |
| Patch test result | |
| Was a consultation form completed? | Yes / No |
| Was informed consent obtained? | Yes / No |
Section D - The Incident
| Field | Details |
|---|---|
| Date the incident occurred or was reported | |
| Time the incident occurred or was reported |
Where did it happen? (tick one)
- Salon
- Client's home
- Mobile location
Address where it happened:
Description of what happened (factual, detailed, in your own words):
What symptoms did the client present? (tick all that apply)
- Redness
- Swelling
- Burning
- Blistering
- Allergic reaction
- Pain
- Bleeding
- Scarring
- Other (describe below)
| Question | Answer |
|---|---|
| Was first aid administered? | Yes / No |
If yes, describe what was done:
| Question | Answer |
|---|---|
| Was emergency services called? | Yes / No |
| If yes, which service? | |
| Reference number |
| Question | Answer |
|---|---|
| Were there any witnesses? | Yes / No |
If yes, provide witness details:
| Witness name | Contact number or email |
|---|---|
Section E - Photographs
| Question | Answer |
|---|---|
| Were photographs taken of the affected area? | Yes / No |
| Date and time of photographs | |
| Where are photographs stored? | |
| Client consent for photographs obtained? | Yes / No |
Section F - Actions Taken
What aftercare advice was given to the client?
| Question | Answer |
|---|---|
| Was the client advised to seek medical attention? | Yes / No |
| Has the client sought medical treatment? (if known) | Yes / No |
| Date insurer was notified (you should notify within 24 hours) | |
| Insurer reference number (once received) |
Section G - Follow Up
| Field | Details |
|---|---|
| Date of follow-up contact with client | |
| Client's condition at follow-up | |
| Any further action taken | |
| Outcome / resolution |
Declaration
I confirm that the information provided in this report is accurate and complete to the best of my knowledge.
| Practitioner signature | |
| Date |
How to use this form
Complete this form AS SOON AS POSSIBLE after the incident. Details fade quickly. The sooner you write it down, the stronger your record will be if you need it later.
Be factual. Describe what happened, not what you think happened. Stick to what you saw, what you did, and what the client told you. Avoid guessing at causes.
Do NOT admit liability or fault in this form. Your insurer will advise you on that. Phrases like "it was my fault" or "I should have done X" can be used against you. Just describe the facts.
Photograph the affected area with the client's consent. Verbal consent is acceptable in an emergency - follow up with written consent as soon as possible. Take clear, well-lit photos and note the date and time.
Notify your insurer within 24 hours. Most policies require this. Late notification can give your insurer grounds to refuse cover. Even if you think the incident is minor, report it. Small reactions can escalate.
Keep this form and all related documents for at least 7 years. This includes photographs, consent forms, consultation records, and product batch information. Store them securely and in line with GDPR. Seven years is the standard limitation period for personal injury claims in the UK.
If the client threatens legal action, do not engage further without contacting your insurer first. Do not apologise in writing, do not offer refunds as an admission, and do not discuss the incident on social media. Let your insurer handle it.
Average allergic reaction claim: £2,000 - £10,000. Poor documentation is the main reason claims are denied. A complete, timely incident report with photographs and product batch numbers gives your insurer what they need to defend you.