Submit A Complaint Online

Please note: If you choose to remain anonymous or
do not provide proper contact information, our
ability to investigate your complaint will be limited.
You must enter a properly formatted email address
to submit this form, but the email address does not
necessarily need to be valid if you wish to remain
anonymous.

Required Fields *

Full Name
Address
City, State, Zip
Home Phone
Work Phone
Email Address *
Date of Incident *
Location of incident
Names of those involved
Prescription Number

Details of Complaint*
Please provide as many specific details as you are able,
including names, dates, addresses, or other information
that may help in the investigation.

Verification*