Pharmacy Premises Committee of the Northern Territory complaint guide and form

(1)

Northern Territory

Pharmacy Premises Committee

Registrar Contact Details PO BOX 40596 Casuarina NT 0811 Telephone: 08 8922 7035 Facsimile: 08 8922 7334 email: [email protected]

COMPLAINT FORM - SCHEDULE 7 HEALTH PRACTITIONERS ACT (NT) PROVISIONS

GENERAL INFORMATION:

 This form is to register complaints relating to breaches of Schedule 7 of the Health Practitioners Act (the Act) which relates to pharmacy premises and ownership

 The Complaint Guide: Schedule 7 Health Practitioners Act 2004 Northern Territory Provisions provides further guidance in the use of this form

 For additional information or assistance please contact the Registrar via the contact details above

 Concerns relating to the practice of practitioners should be referred to the Pharmacy Board of Australia

 Please provide as much detail as possible. The use of additional pages, supporting diagrams and photographs are encouraged.

COMPLAINANT DETAILS:

Name:

Phone: Facsimile:

Mobile: Email:

Postal Address:

Please indicate preferred method of contact:

DETAILS OF THE SUBJECT OF THE COMPLAINT:

Name:

Location:

Has this complaint been lodged with anyone else? (Including the subject of the complaint)  Yes  No If Yes, please provide the details: (Including any responses received)

DETAILS OF COMPLAINT Please tick () all items below which are relevant

Endorsed By: NT Pharmacy Premises Committee Effective Date: 21 February 2012 Last Reviewed: 21 February 2012 Due For Review: 21 February 2015

Page 1 of 2

(2)

Northern Territory