Consumer Complaint Form - California State Board Of Pharmacy
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1
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3California State Board of Pharmacy
BUSINESS, CONSUMER SERVICES AND HOUSING AGE AGENCY
1625 N. Market Blvd, Suite N219, Sacramento, CA 95834
DEPARTMENT OF CONSUMER AFFAIRS
Phone (916) 574-7900
GOVERNOR EDMUND G. BROWN JR.
Fax (916) 574-8618
CONSUMER COMPLAINT FORM
PRINT
RESET
NOTICE:
The information included on the complaint form is requested per section 129 and section 4008 of the Business and
Professions Code. All information requested is voluntary, but failure to provide the requested information may delay or prevent
the investigation of your complaint. The information on the complaint form will be used in part to determine whether a
violation of state pharmacy law has occurred. If a violation is confirmed, the information may be transmitted to other
government agencies, including the Attorney General’s Offices.
PLEASE PRINT OR TYPE
PLEASE PROVIDE ALL THE REQUESTED INFORMATION
E-mail address:
Name of Person
Name of Pharmacy:
Registering Complaint:
Address:
Address:
City:
County:
City:
County:
State:
Zip
State:
Zip
Code:
Code:
Phone No: Wk:( )
Hm ( )
Name of Pharmacist
if known:
Relationship to Patient:
Name of Any Other
Person Involved:
WHEN DID THE PROBLEM OCCUR?
DETAILS OF COMPLAINT
Describe the events in the order they happened, as simply as possible. (Use extra sheets if necessary.)
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Parent category: Legal