Complaint Form
Complainant Name:
Address: City, State, Zip:
Telephone Numbers: Home Business
Patient Name: Date of Birth:
Physician Name: Telephone Number:
Address: City, State, Zip:
Drug Prescribed: Prescription Number:
Pharmacy Name & Address:
STATEMENT OF COMPLAINT: Type or neatly print your complaint below. Be as concise as possible. Use
reverse side if necessary. Make copies and attach any documents you have which support your allegation(s).
After completing your statement of complaint, please sign and date it. The Board does not have jurisdiction
over complaints involving rudeness, customer service and/or pricing/billing disputes.
Please understand that by signing and submitting this form to the Board of Pharmacy, you are authorizing and allowing this Board’s staff to access
your medical history and records, including pharmacy records, as needed to investigate your complaint. If you would like to limit what the Board’s
staff can review, you must inform us of those limitations in writing.
Posted 11/3/2009