Free Pharmacy Complaint Form Template
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)
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Name(s) |
Contact Number |
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Nature of Complaint
Check all that apply:
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Incorrect Medication/Prescription
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Delayed Service
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Staff Behavior
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Billing Issue
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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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