Form C-100 2026

1. Click ‘Get Form’ to open Form C-100 in the editor.
2. Begin by entering your personal information in the 'Name of Person Registering Complaint' section, including your address, phone numbers, and email.
3. Fill in the details about the patient, including their name, date of birth, and your relationship to them.
4. Provide information about the pharmacy involved by entering its name and address. If known, include the pharmacist's name.
5. In the 'Details of Complaint' section, describe the events leading up to your complaint in chronological order. Use additional sheets if necessary.
6. Answer questions regarding any actions taken, such as discussions with the pharmacist and whether counseling was offered.
7. Indicate if you are willing to testify against any individual licensed by the Board of Pharmacy.
8. Review all entered information for accuracy before signing and dating the form at the bottom.

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