Laboratory Information System Complaint Form
Use this form to report issues with your laboratory information system. Please provide all relevant details to help us address your complaint efficiently.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Organization or Laboratory Name
*
System or Module Affected
*
Please Select
Patient Management
Sample Tracking
Results Reporting
Inventory Management
Billing
Other
Complaint Category
*
Please Select
System Error
Performance Issue
Data Entry Problem
Connectivity Issue
User Interface Issue
Other
Urgency Level
*
Critical
High
Medium
Low
Incident Description
*
Date and Time of Incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Desired Resolution or Outcome
Submit Complaint
Should be Empty: