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Pharmacy : complaint

Complaint Forms and Publications


Download Board of Pharmacy Complaint Form:

                           In Microsoft Word Format
                           In Adobe Acrobat Format
                           In Espanol

Click Here to find out how your complaint information will be used.

eMail Complaint Form to:  dhmh.mdbop@maryland.gov or
Fax (410)358-6207 Complaint form to the Board

Other Complaint & Reporting Organizations

Free Guidance for Consumers on Prescription Medicines
Best Buy Drugs is a public education project. It will help you talk to your doctor about prescription drugs, and find the most effective and safe drugs that also give you the best value for your health care dollar.
www.consumerreports.org

Report to the Board of Pharmacy missing or stolen prescription pads - Click Here

ONLINE FORM COMING SOON

PLEASE DOWNLOAD COMPLAINT FORMS FOR SUBMISSION

 

 

 

 

 

 

Name of Complainant 
Address 
City 
State 
Zip Code 
Home Telephone # 
Business Telephone #
 
Name of person preparing this complaint if it differs from above (Section 1) 
Address 
City 
State 
Zip Code 
Home Telephone # 
Business Telephone # 
   
Name of pharmacist(s) named in complaint 
Name of pharmacy involved in complaint 
Address of pharmacy involved in complaint 
City 
State 
Zip Code 
   
If your complaint is against a  distributor of drugs, please give:
Name of the firm 
Address 
City 
State 
Zip Code 
   
If you have made a complaint to any other government agency, professional association, etc. about this matter, please indicate their names and addresses below:
 
 
If your complaint involves a prescription drug, please write down all of the information appearing on prescription label:
Date incident occurred: 
 
In your own words, state in as much detail as possible the exact nature of your complaint. Use as much space as necessary.
 
Have you discussed your complaint with pharmacist or firm about whom you are complaining:
   Yes    No
 
State the names addresses, and telephone numbers of all persons who witnessed or may have any additional information about your complaint.
 
State the name of the physician or other authorized prescriber who provided the prescription for the medication involved in your complaint.
Prescriber's Name 
Address 
City 
State 
Zip Code 
 
Do you consent to the release to this Board and its investigators of any medical records to you and this incident from any hospital or related institution or physician?
   Yes    No
 
I HEREBY DECLARE AND AFFIRM UNDER PENALTIES OF PERJURY THAT THE MATTERS SET FORTH IN THE FOREGOING COMPLAINT ARE TRUE AND CORRECT, TO THE BEST OF MY KNOWLEDGE, INFORMATION, AND BELIEF.
 
Signature of complainant 
Date 
Signature of person preparing complaint, if not the person above 
Date