Medication Non-Delivery Complaint Form
Use this form to report a medication order that was not received and provide the details needed for follow-up.
Reporter and Order Details
Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Order or Prescription Reference Number
*
Medication and Delivery Information
Medication Name
*
Expected Delivery Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Delivery Address or Destination
*
Delivery Status
*
Not delivered
Delivered to wrong address
Marked delivered but not received
Other
Complaint Details and Resolution Request
Description of what happened
*
Preferred resolution or action
*
Resend medication
Refund
Investigation requested
Contact me first
Submit Complaint
Should be Empty: