We are here to assist you!
Please complete the form below for your complaints.
Date of filling the form:
-
Month
-
Day
Year
Date Picker Icon
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
Minutes
AM
PM
AM/PM Option
Complainant's Name:
*
E-mail
*
Phone Number
*
-
Area Code
Phone Number
The complaint is regarding:
*
The nature of complaint:
*
Name of the company/person against which/whom the complaint is filed:
Pyramids Pharmacy
Pyramids Pharmacy TMC
Pyramids Pharmacy Webster
Pyramids Infusion Center
Wellness Clinic
Pyramids Specialty Pharmacy
Pyramids Mail Order Pharmacy
Pyramids Staff Member
Name of the individual person against which/whom the complaint is filed if applicable:
The specific details of the complaint:
*
Please verify that you are human
*
Send
Should be Empty:
Now create your own JotForm - It's free!
Create your own JotForm