Complaint, Comment, or Suggestion Form

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Please use this form for complaints, comments, or suggestions.

Your input will be forwarded to management for review and evaluation.

If you wish to be contacted, then please provide your contact information.

We appreciate your time to complete this form to help us improve our service.

A red asterisk "*" indicates a required field.

Otherwise, all other fields are optional.

Sincerely,

Oakland Pharmacy, Inc.

Date of Incident or Today's Date
*

YYYY

Time of Incident

Time

Please select location that was involved.

Provide a description of your complaint, comment, or suggestion.

If your concern involves a prescription filled by our pharmacy, then, if possible, please include the patient's name and medication name.

If you wish to be contacted regarding your entry, then please provide your first & last name and contact information (phone number and/or email).

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