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COMPLAINANT:
ADDRESS:       
CITY:                    STATE:    ZIP:
TELEPHONE:    CONVENIENT TIME TO CALL:
E-MAIL ADDRESS:

PLEASE GIVE NAME & ADDRESS OF INDIVIDUAL/BUSINESS SUBJECT 
TO THE COMPLAINT

NAME:       
ADDRESS: 
CITY:             STATE:    ZIP:

DOES THIS COMPLAINT INVOLVE A MIS-FILLED PRESCRIPTION?
  Yes    No 

PLEASE GIVE IN DETAIL THE NATURE OF THE COMPLAINT, INCLUDE 
TIME, DATE AND NAMES OF PERSONS WHO MAY HAVE WITNESSES 
THE ALLEGED ACT. THE ALLEGED VIOLATION MAY RESULT IN A HEARING AND ALL INFORMATION IS IMPORTANT. 


ACTION YOU WOULD LIKE THE BOARD TO TAKE REGARDING YOUR COMPLAINT: