Kansas Board of Pharmacy
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Kansas Board of Pharmacy Complaint System
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Complaint #: C-851
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Patient Information
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Pharmacist / Physician Information
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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
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Files Associated with the Complaint
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