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Please describe your complaint in detail; include facts, dates, and names of persons involved. If your complaint involves a prescription, please provide information from the prescription label. The Board does not have jurisdiction over complaints involving rudeness, customer service and/or pricing/billing disputes. * This page will timeout, please keep your time to under 40 minutes when entering your complaint.

Complaint Report Form

Your Name (required)
Date of Birth
(format: mm/dd/yyyy)
Drivers' License Number
Your Postal Address (required)
City/State/Zip (required)
Home Phone (required) (Include Area Code)
Work Phone (Include Area Code)
Email Address (Optional)
   
Name of Individual
Name of Pharmacy (required)
Address (required)
City/State/Zip (required)
Phone (Include Area Code)
Details of the Complaint (required)
Rx Number
Date of Rx
(format: mm/dd/yyyy)
(Click on Calendar icon to add date)
Patient's Name
Patient's Date of Birth
(format: mm/dd/yyyy)
Doctor's Name
Drug Name and Strength
Directions for use
Quantity
# of Refills
Have you contacted the business or individual about your complaint?
If yes, please give a date?
(format: mm/dd/yyyy)
(Click on Calendar icon to add date)
If yes, what was the response?
Have you filed a complaint regarding this matter with another agency?
If yes, which agency?
If yes, what action was taken?
    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.
    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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