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COMPLAINT DETAILS
PHARMACY NAME
PHARMACIST/TECHNICIAN COMPLAINT IS AGAINST:
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Explain the incident in your own words
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Complaint Filed By
I attest that all statements made by me related to this complaint are true to the best of my knowledge and belief. I understand that I may be called as a witness to testify in any proceedings that may result from this complaint.
First Name
Middle Name
Last Name
Business Name
Address
City
State
Zip
Select State
AK
AL
AP
AR
AZ
CA
CO
CT
DC
DE
FC
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MI
MN
MO
MS
MT
NB
NC
ND
NE
NH
NJ
NM
NS
NV
NY
OH
OK
ON
OR
PA
PE
PR
QC
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Email
Phone
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Home
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Business
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Home
Cell
Business
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BY SUBMITTING THIS FORM YOU ATTEST THIS COMPLAINT TO BE TRUE AND FACTUAL