"Consumer Complaint Form - Prescription Error" - Connecticut

Consumer Complaint Form - Prescription Error is a legal document that was released by the Connecticut State Department of Consumer Protection - a government authority operating within Connecticut.

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Download "Consumer Complaint Form - Prescription Error" - Connecticut

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STATE OF CONNECTICUT
DEPARTMENT OF CONSUMER PROTECTION
DRUG CONTROL DIVISION
165 CAPITOL AVE.
HARTFORD, CT 06106
Fax: (860) 706‐1350 
Phone: (860) 713‐6065 
Please e-mail completed form to
dcp.rxerror@ct.gov
Consumer Complaint Form
Please fill this form out as completely and accurately as you can. Thank you.
Name of Person Registering Complaint:
Phone Number:
Email Address
Address:
City:
Zip Code:
Patient Name (if different):
Patient Date of Birth:
Relationship to Patient (if applicable:)
Name of Pharmacy:
Address of Pharmacy:
City:
State:
Zip Code:
Date the Prescription Was Filled:
Date the Issue Was Found
Prescription Number (if applicable):
Medication Prescribed (Name & Strength):
Medication Dispensed (name & strength):
Pharmacist Name (if known):
Have you discussed this matter with the pharmacist or a pharmacy representative?
Yes
No
If yes, on what date__________________
If complaint involves a prescription error, is the evidence available?
Yes
No
If yes, where is the evidence? ____________________________________
Has the pharmacy been contacted about this error?
Yes
No
If yes, on what date__________________
Type of Error (please select the error type(s) that are most similar to your situation:
 Wrong Medication
 Expired Medication
 Other___________________________
 Wrong Patient Name
 Mixed Medication
 Wrong Strength
 Received someone else’s medication
 Wrong Directions
 Wrong Quantity
Briefly describe the events related to the complaint in the order in which they happened:
STATE OF CONNECTICUT
DEPARTMENT OF CONSUMER PROTECTION
DRUG CONTROL DIVISION
165 CAPITOL AVE.
HARTFORD, CT 06106
Fax: (860) 706‐1350 
Phone: (860) 713‐6065 
Please e-mail completed form to
dcp.rxerror@ct.gov
Consumer Complaint Form
Please fill this form out as completely and accurately as you can. Thank you.
Name of Person Registering Complaint:
Phone Number:
Email Address
Address:
City:
Zip Code:
Patient Name (if different):
Patient Date of Birth:
Relationship to Patient (if applicable:)
Name of Pharmacy:
Address of Pharmacy:
City:
State:
Zip Code:
Date the Prescription Was Filled:
Date the Issue Was Found
Prescription Number (if applicable):
Medication Prescribed (Name & Strength):
Medication Dispensed (name & strength):
Pharmacist Name (if known):
Have you discussed this matter with the pharmacist or a pharmacy representative?
Yes
No
If yes, on what date__________________
If complaint involves a prescription error, is the evidence available?
Yes
No
If yes, where is the evidence? ____________________________________
Has the pharmacy been contacted about this error?
Yes
No
If yes, on what date__________________
Type of Error (please select the error type(s) that are most similar to your situation:
 Wrong Medication
 Expired Medication
 Other___________________________
 Wrong Patient Name
 Mixed Medication
 Wrong Strength
 Received someone else’s medication
 Wrong Directions
 Wrong Quantity
Briefly describe the events related to the complaint in the order in which they happened: