MD Board of Pharmacy - Forms and Publications

Forms and Publications

Complaint Form	Licensure Applications	Permit Applications
Newsletters	Brochures	Annual Report

Download Board of Pharmacy Complaint Form:
                         In Microsoft Word Format
                         In Adobe Acrobat Format
                           In Web Page Format
                           In Espanol
Click Here to find out how your complaint information will be used.

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

Other Complaint & Reporting Organizations

Health Licensing Boards
Labor Profession Licensing Boards
State Attorney General - Consumer Protection
Better Business Bureau

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

Submit Online Complaint Form

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.
Presriber'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

Last Updated: 04/07/2009