Complaint Form

Complainant's Information

Please provide your personal information below.


Name of person submitting the complaint:
Address:
City:	State:	ZIP Code:
Email:	Phone:

Patient Information

Name of patient involved in the incident which gives rise to this complaint:

Complaint Information


Pharmacy or pharmacist about whom you are complaining:	Date of the incident giving rise to this complaint:
Place (pharmacy) where the incident giving rise to this complaint occurred:
Please describe below 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 upload copies of those items by clicking the button below. Drop file(s) here or Uploaded File(s) Click here for recommendations on uploading files.

Certification

By checking this box, I hereby declare that all of the information I have provided with this form is true and correct.