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NORTH DAKOTA STATE BOARD OF PHARMACY |
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NORTH DAKOTA STATE BOARD OF PHARMACY |
Today’s Date mm/dd/yy Name of Person Submitting the Complaint Address of Person Submitting the Complaint Address City State Zip Contact Phone eg. 701-000-0000 Name of the Pharmacy or Pharmacist About Whom You Are Complaining
Name of Patient Involved in the Incident Which Gives Rise to This Complaint Place (Pharmacy) Where the Incident Giving Rise to This Complaint Occurred Date of the Incident Giving Rise to This Complaint mm/dd/yy Please describe the conduct about which you are complaining. It is important to be as specific as is reasonably possible. If you are in possession of medical records or other documents such as labels or prescription containers which support your allegations, you should attach copies of those items to this form or specify where we can obtain them.
"I hereby declare that all of the information I have provided
with this form is true and correct."By hitting the submit button you are certifying this statement.