RX Abuse Online Reporting: Report Incident

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Complaint Type* :

- Select One - Dr. Shopping Employee Drug Dealing/Theft Forged/Stolen Prescription Pad INTERNET - ILLEGAL DRUG SALES Illegal Drug Distribution Illegal Drug Trafficking Organization Patient Selling Drugs Stolen/Abused DEA Reg Number Suspicious Doctor/Practitioner Suspicious Pain Clinic/Med Facility Suspicious Pharmacy/Pharmacist Other

Person Making the Report

First Name		Phone Numbers: Cell:    Home: Other:
Last/Business Name
Your Zip Code*

Location of Incident

Location is same as person making the report:
Zip Code*
State*	- Select State - ARMED FORCES AMERICAS ARMED FORCES EUROPE ALASKA ALABAMA ARMED FORCES PACIFIC ARKANSAS AMERICAN SAMOA ARIZONA CALIFORNIA COLORADO CONNECTICUT DISTRICT OF COLUMBIA DELAWARE FLORIDA FED. STATES OF MICRONESIA GEORGIA GUAM HAWAII IOWA IDAHO ILLINOIS INDIANA KANSAS KENTUCKY LOUISIANA MASSACHUSETTS MARYLAND MAINE MARSHALL ISLANDS MICHIGAN MINNESOTA MISSOURI NORTHERN MARIANA ISLANDS MISSISSIPPI MONTANA NORTH CAROLINA NORTH DAKOTA NEBRASKA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEVADA NEW YORK OHIO OKLAHOMA OREGON PENNSYLVANIA PUERTO RICO PALAU RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VIRGINIA VIRGIN ISLANDS VERMONT WASHINGTON WISCONSIN WEST VIRGINIA WYOMING
Messages:
City*

Description

Briefly describe situation being reported - who, what, where and when. 1200 Characters Maximum *

Characters Remaining:

(* indicates a required field)

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