Untitled Document

Complaint Form – Prices of Patented Medicines Sold in Canada

Name (Please indicate if you represent a group and, if so, please provide contact information for the group as well):

Contact Information:

Mailing Address:

Email Address:




Drug product name:



Pharmaceutical company:

Price of the drug product (excluding pharmacist's fees):

Date of Purchase:

Province of purchase:

Any additional information:

Confidentiality and Disclosure

The PMRPB makes every attempt to preserve the confidentiality of a complaint as provided for under the Privacy Act. However, if the subject of the complaint becomes the subject of a public hearing, it may not remain fully confidential.

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