Untitled Document
Complaint Form – Prices of Patented Medicines Sold in Canada
Name (Please indicate if you represent a group and, if so, please provide contact information for the group as well):
Contact Information:
Mailing Address:
Email Address:
Telephone:
Fax:
Cell:
Drug product name:
Dosage:
DIN:
Pharmaceutical company:
Price of the drug product (excluding pharmacist's fees):
Date of Purchase:
Province of purchase:
Any additional information:
Confidentiality and Disclosure
The PMRPB makes every attempt to preserve the confidentiality of a complaint as provided for under the Privacy Act. However, if the subject of the complaint becomes the subject of a public hearing, it may not remain fully confidential.