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You are about to submit notification of a complaint against this individual or facility to the Kansas Board of Pharmacy. Failure to provide supporting details, information, and/or documents sufficient for the Board to investigate the matter will result in your complaint being closed without further review. For specific information about what should be included prior to submitting a complaint, please review the Board’s C-100 complaint form at

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Patient Information
Pharmacist / Physician Information
Complaint Overview
When did the problem(s) occur?
Have you discussed the matter with the pharmacist?
Name of person contactedDate of contact 
How was contact made?
FURTHER INFORMATION     Complete only if applicable
Prescribing DoctorTelephone #
Address of DoctorCityStateZip
Medication PrescribedMedication ReceivedPrescription #
The prescription was:
Was there harm to the patient?
 If yes, describe briefly:
Was counseling offered by the pharmacy?
Was counseling declined by the patient?
Was the counseling provided by the pharmacist?
Was counseling provided by another individual? If so, who:
Was any of the medication taken or used?
Do you still have the medication?
Do you still have the container/label? (If you have the medication and/or container, please retain them until further notified by the board inspector)
If this complaint is against an individual licensed by the Board of Pharmacy, would you be willing to testify?
Drug Information
Files Associated with the Complaint