Free Pharmacy Complaint Form

Please complete all sections to ensure we can address your complaint effectively.
Personal Information
Name
Address
Phone Number
Complaint Details
Date of Incident
Location Address/Branch of Pharmacy
Staff Member(s) Involved (if applicable)
Name(s) | Contact Number |
|---|---|
Nature of Complaint
Check all that apply:
Incorrect Medication/Prescription
Delayed Service
Staff Behavior
Billing Issue
Product Availability
Description of Incident
Provide a detailed account of what occurred. Attach additional pages if necessary.
Action Taken
Have you reported this issue to anyone else?
If yes, please specify:
Desired Resolution
Describe how you would like this to be resolved.
Supporting Document
Upload a file to support the complaint.
By signing below, I affirm that the information provided is accurate to the best of my knowledge.
Name:
Date:
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