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Complaint Overview

When did the problem(s) occur?

ACTION TAKEN Yes No Have you discussed the matter with the pharmacist? Name of person contacted Date of contact   How was contact made? By Phone Letter/Email Person No contact made   FURTHER INFORMATION     Complete only if applicable Prescribing Doctor Telephone # Address of Doctor City State Zip Medication Prescribed Medication Received Prescription # The prescription was: for a new prescription a refill a new prescription for a medication taken or used previously Other Yes No Was there harm to the patient?   If yes, describe briefly: Yes No Was counseling offered by the pharmacy? Yes No Was counseling declined by the patient? Yes No Was the counseling provided by the pharmacist? Yes No Was counseling provided by another individual? If so, who: Yes No Was any of the medication taken or used? Yes No Do you still have the medication? Yes No 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) Yes No If this complaint is against an individual licensed by the Board of Pharmacy, would you be willing to testify?

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