Fake Prescription Report Form
Report suspected fake prescription activity. Please provide as much detail as possible. Do not include sensitive personal or financial information.
Are you reporting as an individual or on behalf of an organization?
*
Individual
Organization
Prefer not to say
Your Name (optional)
Your Email (optional, for follow-up)
example@example.com
Date of suspected fake prescription activity
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Location of the activity (pharmacy, clinic, or address)
*
Describe the suspected fake prescription activity
*
Who was involved? (names, descriptions, or roles if known)
Upload any supporting documents or images (optional)
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Have you reported this activity elsewhere?
Yes
No
Additional comments (optional)
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