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Questions to Ask Your Pharmacist
Drug Monitoring Program

Drug Repository Program
Retail Meth Watch

Complaint Form

Today’s Date: mm/dd/yy
Name of Person Submitting the Complaint:
Address of Person Submitting the Complaint
Address: 
City:
State:
Zip Code:
Contact Phone: eg. 701-000-0000
Email:
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 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 attach copies of those items to this form or specify where we can obtain them.