Lodge a Formal Complaint or Raise Concerns This form is for lodging a formal complaint about a pharmacist, or to help you convey your concerns about a pharmacist, with the Pharmacy Council. Before completing this form, you should consider talking to the pharmacist you are unhappy with. The Health and Disability Commissioner (HDC) may also offer you other options to resolve the matter. We collect personal information from you, including your contact details and health information. The Privacy Act and the Health Information Privacy Code allow us to collect, use and disclose personal information (including personal health information), only in ways authorised by the Privacy Act. To help resolve your complaint, we may also collect information from other parties regarding your complaint, including (if required) the relevant clinical records. You have the right to ask for a copy of any personal information we hold about you, and to ask for it to be corrected if you think it is wrong. When a complaint is made about a pharmacist, the pharmacist is provided with all the information received with the complaint, and they must be given a reasonable opportunity to respond. Complaints relating to health services provided to a patient / health service user / member of the public, who has been harmed by the actions of a pharmacist, should be made directly with HDC so that the patient may be contacted directly. However, it would help us to be aware of the complaint, and you can provide a summary of the complaint on the form below. You can access the HDC website to lodge a formal complaint using the following link: https://www.hdc.org.nz/making-a-complaint/ (opens in a new tab), or free phone 0800 555 050 if you wish to speak with the HDC Advocacy Service. Or, if you prefer, we can forward the complaint to HDC on your behalf, but please confirm this in the "Additional Details" box in the form. If you have any questions about any of the above, or have a general enquiry, please contact us at enquiries@pharmacycouncil.org.nz, phone 04 495 0330, or post to PO Box 25137, Wellington 6140. About youName* First Last Phone*Please include your area code (e.g. 04 495 0330) Email* Postal address (optional) Address Line 1 Address Line 2 City Region Post Code New ZealandAustraliaUnited KingdomUnited StatesWestern SamoaBermudaIraqIran, Islamic Republic OfTaiwanQatarNigeriaZimbabwePakistanGhanaTongaIndiaRomaniaSlovakiaSri LankaPhilippinesYugoslaviaCroatiaGermanyKorea, Republic of (South)IsraelChinaSpainSyrian Arab RepublicMaltaTanzania, United Republic OfItalyZambiaMauritiusSerbiaAlgeriaPolandSwazilandSwedenNetherlandsBotswanaHungaryNamibiaRussian FederationYemenIndonesiaLibyaBangladeshKenyaFinlandBosnia And HerzegovinaJordanKuwaitLebanonMacedonia, The Former Yugoslav Republic OfNew CaledoniaSudanTurkeyAfghanistanÅland IslandsAlbaniaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua And BarbudaArgentinaArmeniaArubaAzerbaijanBahamasBahrainBarbadosBelarusBelizeBeninBhutanBoliviaBouvet IslandBrazilBritish Indian Ocean TerritoryBulgariaBurkina FasoBurundiCambodiaCameroonCape VerdeCayman IslandsCentral African RepublicChadChileChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo, The Democratic Republic Of TheCosta RicaCote D'ivoireCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGibraltarGondwanaGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandsHoly See (Vatican City State)HondurasIcelandJamaicaJefflandKazakhstanKiribatiKorea, Democratic Peoples Republic Of (North)KyrgyzstanLao People's Democratic RepublicLatviaLesothoLiberiaLiechtensteinLithuaniaLuxembourgMacaoMacedonia, The Former Yugoslav Republic OfMadagascarMalawiMaldivesMaliMarshall IslandsMartiniqueMauritaniaMayotteMexicoMicronesia, Federated States OfMoldova, Republic OfMonacoMongoliaMontserratMoroccoMozambiqueMyanmarNauruNepalNetherlands AntillesNicaraguaNigerNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPalestinian Territory, OccupiedPanamaParaguayPeruPitcairnPortugalPuerto RicoReunionRussian FederationRwandaSaint HelenaSaint Kitts And NevisSaint LuciaSaint Pierre And MiquelonSaint Vincent And The GrenadinesSamoaSan MarinoSao Tome And PrincipeSenegalMontenegroSeychellesSierra LeoneSloveniaSolomon IslandsSomaliaSouth Georgia And The South Sandwich IslandsSurinameSvalbard And Jan MayenSyrian Arab RepublicTajikistanTanzania, United Republic OfTimor-LesteTogoTokelauTrinidad And TobagoTunisiaTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis And FutunaWestern SaharaAustriaBelgiumBrunei DarussalamCanadaCook IslandsEgyptFalkland Islands (Malvinas)FijiFranceHong KongIrelandJapanMalaysiaPapua New GuineaRepublic of PalauSaudi ArabiaSingaporeSouth AfricaSwitzerlandThailandUnited Arab Emirates Country This field is hidden when viewing the formDo you wish to:* Raise a concern Lodge a formal complaint Make a health notification Make a competence notification Raise a concernLodge a formal complaint Formal complaints (complaints which relate to a patient / health service user /member of the public, who has been harmed by the actions of a pharmacist), should be made to the Health and Disability Commissioner (HDC). You may provide a summary of the complaint here before lodging it with the HDC. Please use the following link to go to the HDC website to lodge a formal complaint: https://www.hdc.org.nz/making-a-complaint/make-a-complaint-to-hdc/Make a competence notification Use this form if you have a concern about the competence of a pharmacist and can substantiate these concernsMake a health notification A registered pharmacist is required to be 'fit to practise'. Use this form if you have concerns that a pharmacist is unable to perform the functions required for the practise of pharmacy because of some mental or physical condition.Have you, or a health service user (member of the public), experienced any harm from the actions of a pharmacist?* Yes No If you have been harmed as a result of the actions of a pharmacist, you should make your complaint directly with HDC. We do, however, encourage you to provide a summary of the complaint on this page. You can access the HDC website to lodge a formal complaint by using the following link (opens in a new tab): https://www.hdc.org.nz/making-a-complaint/make-a-complaint-to-hdc/, or free phone the HDC Advocacy Services on 0800 555 050. You are taking this action as a:* Health service user (member of the public) Health professional Formal complaints (complaints which relate to a health service user / member of the public who has been harmed by the actions of a pharmacist), should be made to the Health and Disability Commissioner (HDC): https://www.hdc.org.nz/making-a-complaint/make-a-complaint-to-hdc/ or free phone the HDC Advocacy Services on 0800 555 050. What is your profession?*PharmacistMedical DoctorNurseOtherType of health professional (other)*Summary of complaint*Please provide a summary of events relating to your complaint. Formal complaintAre you wanting to lodge a formal complaint on behalf of a patient?* Yes No We may contact you directly to confirm these details. Formal complaints (complaints which relate to a health service user / member of the public who has been harmed by the actions of a pharmacist), should be made to HDC using the following link (opens in a new tab): https://www.hdc.org.nz/making-a-complaint/make-a-complaint-to-hdc/, or free phone the HDC Advocacy Services on 0800 555 050. What is your relationship to the patient?*Name of the patient* First Last Is the patient aware that you are lodging this complaint?* Yes No Why is the patient not aware of your lodging this complaint?*Is the person for whom you are making this complaint still receiving the services from the pharmacist/pharmacy?* Yes No Please select the age group of the patient (optional) Under 14 15-24 25-34 35-44 45-54 55-64 65-74 75+ Prefer not to answer Please specify the gender of the patient (optional) Male Female Gender diverse Please specify the ethnicity of the patient (optional)New Zealand MaoriNew Zealand EuropeanOther EuropeanSamoanCook Island MaoriTonganNiueanChineseIndianOtherOther Pacific Island GroupsOther AsianTokelauanEuropeanPacific IslandFijianAsianSoutheast AsianMiddle EasternLatin American/HispanicAfricanUnknownName and address of the pharmacy (optional)Is the complaint about an experience at this pharmacy?* Yes No Do you wish to lodge a formal complaint about the actions of a pharmacist?* Yes No Is the complaint about more than one pharmacist?* Yes No Name of the pharmacist*Names of pharmacists What is your relationship to the pharmacist/pharmacy?* Patient Health service user (member of the public) Professional Colleague Employer Other n/a DetailsHas a patient experienced any harm from the actions of the pharmacist?* Yes No Details of your concern:Please share your concern and include the reasons for your concern. Details of your competence notificationPlease include all the details which support your view that this pharmacist may pose a risk of harm to the public by practising below the standard expected and required of a pharmacist. Do you think this pharmacist poses a risk of harm to themselves or the public?* Yes No Have you sought medical advice prior to making this notification?*Please note: it is not a requirement, however, it may help to support your notification. You may upload supporting documentation at the end of this form. Yes No Please include all the details which support your view that this pharmacist is unable to perform the functions required for the practise of pharmacy because of some mental or physical condition.Please include all the details which support your view that this pharmacist is unable to perform the functions required for the practise of pharmacy because of some mental or physical condition. Details*Please include dates and times, whether the patient received incorrect medicines or doses, details of medicine, staff interaction, whether the patient was hospitalised, and details of any harm suffered by the patient. OutcomeHave you discussed the matter with the pharmacist?* Yes No Please provide details*Please provide details, including any outcomes of your discussions with the pharmacist. You can upload documents at the end of this form. Have you contacted any other agencies about this matter?* Yes No Have you contacted any other agencies about this matter?*(e.g. Health and Disability Commissioner (HDC), Accident Compensation Corporation (ACC), the Human Rights Commission, the Privacy Commissioner, the Police) Yes No Please provide details*Please provide details, including any outcomes, following your contact with an agency/agencies. You can upload documents at the end of this form. The Code of Health and Disability Services Consumers' Rights (the Code) establishes the rights of consumers, and the obligations and duties of providers to comply with the Code. It is a regulation under the Health and Disability Commissioner Act. The Nationwide Health and Disability Advocacy Service (the Advocacy Service) is a free service that operates independently from all health and disability service providers, government agencies, and the Health and Disability Commissioner (HDC). Its role is to support you to express and try to resolve your concerns. Advocates are not investigators or mediators, and do not make decisions on whether there has been a breach of the Code. For more information about the HDC Advocacy Service, please visit the HDC Advocacy website: https://www.advocacy.org.nz/ File uploadsFiles (optional)Please upload any relevant documentation Drop files here or Select files Accepted file types: jpg, jpeg, pdf, doc, docx, png, gif, xls, xlsx, Max. file size: 2 MB. What happens nextPlease lodge your complaint with the Health and Disability Commissioner (HDC) . The information you provide to Council will be assessed to indentify what actions Council may be required to take in addition to any taken by HDC. Please be advised that a copy of the complaint and any supporting documentation provided by you will be sent to the pharmacist/s who is/are the subject of the complaint so they are able to make an informed submission to Council on this matter. Thank you for completing this form, a Pharmacy Council staff member will be in touch with you soon. Demographics (optional)Demographics are collected for statistical purposes only and will be anonymised. Please select your age group Under 14 15-24 25-34 35-44 45-54 55-64 65-74 75+ Prefer not to answer Please specify your gender Male Female Gender diverse Please select your ethnicityPlease selectNew Zealand MaoriNew Zealand EuropeanOther EuropeanSamoanCook Island MaoriTonganNiueanChineseIndianOtherOther EuropeanOther Pacific Island GroupsOther AsianTokelauanEuropeanPacific IslandFijianAsianSoutheast AsianMiddle EasternLatin American/HispanicAfricanUnknownFeedback (optional)If you have any feedback about this form or process, please add your comments below
