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Complaint Report Form
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| Your Name |
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Date of Birth
(format: mm/dd/yyyy) |
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| Drivers' License Number |
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| Your Postal Address |
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| City/State/Zip |
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| Home Phone |
(Include Area Code) |
| Work Phone |
(Include Area Code) |
| Email Address |
(Optional) |
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| Name of Individual |
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| Name of Pharmacy (required) |
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| Address (required) |
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| City/State/Zip (required) |
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| Phone |
(Include Area Code) |
| Details of the Complaint (required) |
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| Rx Number |
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Date of Rx
(format: mm/dd/yyyy) |
(Click on Calendar icon to add date)
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| Patient's Name |
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Patient's Date of Birth
(format: mm/dd/yyyy) |
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| Doctor's Name |
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| Drug Name and Strength |
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| Directions for use |
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| Quantity |
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| # of Refills |
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| Have you contacted the business or individual about
your complaint? |
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If yes, please give a date?
(format: mm/dd/yyyy) |
(Click on Calendar icon to add date)
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| If yes, what was the response? |
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| Have you filed a complaint regarding
this matter with another agency? |
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| If yes, which agency? |
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| If yes, what action was taken? |
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I authorize the
Texas State Board of Pharmacy to disclose my identity, as the person
who filed the complaint, to the subject(s) of my complaint, and other
persons during the course of the agency's investigation and/or
prosecution of my complaint. |
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I DO NOT authorize the Texas
State Board of Pharmacy to disclose my identity, as the person who
filed the complaint, to the subject(s) of my complaint, and other
persons during the course of the agency's investigation and/or
prosecution of my complaint. Please be advised that without
authorization TSBP may close your complaint with no further action.
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