Georgia Professional Licensure Complaint Form

Pharmacy

NOTE: All fields marked with astericks (*) are mandatory.

Your Name (required)

Your Address (required)

Complete Address (include street, city, state and zip)

Your Telephone (required)

Enter area code and phone number as 123-456-7890

FAX

Enter area code and phone number as 123-456-7890

Your E-mail (required)

Area of Complaint

Quality of Care/Service

Unlicensed Practice

Unprofessional Conduct

Other

Name of Licensee/Professional Entity

License Number

Licensee/Facility Address

Complete Address (include street, city, state and zip)

Licensee/Facility Phone

Enter area code and phone number as 123-456-7890

Have you brought any legal action against this licensee/professional entity?

Yes

Detailed Complaint Information

Please provide a detailed explanation of your complaint. Include names, addresses, dates, etc. regarding all parties involved.