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Form C-100 2026
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- Click ‘Get Form’ to open Form C-100 in the editor.
- Begin by entering your personal information in the 'Name of Person Registering Complaint' section, including your address, phone numbers, and email.
- Fill in the details about the patient, including their name, date of birth, and your relationship to them.
- Provide information about the pharmacy involved by entering its name and address. If known, include the pharmacist's name.
- In the 'Details of Complaint' section, describe the events leading up to your complaint in chronological order. Use additional sheets if necessary.
- Answer questions regarding any actions taken, such as discussions with the pharmacist and whether counseling was offered.
- Indicate if you are willing to testify against any individual licensed by the Board of Pharmacy.
- Review all entered information for accuracy before signing and dating the form at the bottom.
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2016 | 4.8 Satisfied (101 Votes) |
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To be registered as a charitable organization, an applicant must execute a consent to service of process on Form C100 provided by the Secretary of State