Complaint Form

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COMPLAINT DETAILS

PHARMACY NAME	PHARMACIST/TECHNICIAN COMPLAINT IS AGAINST:

Address

City	State	Zip	Phone

Explain the incident in your own words (Limit: 2000 characters) Characters Used: 0

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

Email		Phone	Alternate Phone

BY SUBMITTING THIS FORM YOU ATTEST THIS COMPLAINT TO BE TRUE AND FACTUAL