Welcome to the General Online Complaint Form

Business/Professional You Want To File A Complaint Against:

Fields marked with an asterisk (*) are required.

Business / Professional Name*:

License Number:

Address (Number and Street)*:

City *:

State *: California Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code *:

Telephone Number: () -

Person whom you dealt with:

Business / Professional E-mail Address:

Please briefly describe your complaint *:

What was the date of Purchase/Incident (mm/dd/yyyy):

If the incident involves a prescription, list the following information below:
New or Refill prescription, Medication Prescribed, Medication Received, Prescription Number, Prescribing Doctor, Was Patient Consultation Provided, Was There Patient Harm *:

Please list supporting documents in your possession such as prescription container, medication, receipts, pictures, etc.:

Are you the patient?

Yes   No

If no, please indicate the patient's name below:

Please retain all supporting documentation as the online complaint process does not support attachments

INFORMATION COLLECTION, ACCESS AND DISCLOSURE

The information you provide on this complaint form is maintained by the Executive Office of the Board of Pharmacy, 2720 Gateway Oaks Drive, Suite 100, Sacramento, CA 95833. The information is requested pursuant to Business and Professions Code Sections 325 and 326.

Submission of all information requested is voluntary. However, omission of any required information will result in your complaint being rejected as incomplete and it will not be successfully submitted.

Your completed complaint form becomes the property of the Board and will be used by authorized personnel as appropriate. Information concerning your complaint may be transferred to other governmental or law enforcement agencies.

You have the right to review the records maintained on you by the department unless the records are exempt by section 1798.40 of the Civil Code. You may gain access to the information by contacting the department at the above address.

About You:

Fields marked with an asterisk (*) are required

Enter your first name *:

Enter your last name *:

Enter your address (Number and Street) *:

City *:

State *: California Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code *:

Daytime Telephone Number: () -

E-mail Address:

Authorization for Release of Medical Information