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, 1625 N Market Blvd, Suite N219,
Sacramento, CA 95834. 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.
Authorization for Release of Medical Information