Complaint #: C-851

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Complaint Overview

When did the problem(s) occur?

ACTION TAKEN YesNo Have you discussed the matter with the pharmacist? Name of person contacted Date of contact   How was contact made? By PhoneLetter/EmailPersonNo contact made   FURTHER INFORMATION     Complete only if applicable Prescribing Doctor Telephone # Address of Doctor City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Medication Prescribed Medication Received Prescription # The prescription was: for a new prescriptiona refilla new prescription for a medication taken or used previouslyOther YesNo Was there harm to the patient?   If yes, describe briefly: YesNo Was counseling offered by the pharmacy? YesNo Was counseling declined by the patient? YesNo Was the counseling provided by the pharmacist? YesNo Was counseling provided by another individual? If so, who: YesNo Was any of the medication taken or used? YesNo Do you still have the medication? YesNo 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) YesNo If this complaint is against an individual licensed by the Board of Pharmacy, would you be willing to testify?

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