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Forgery Report Form for Controlled Substances

Cat. No.: HC/SC 4004 (10-2004)

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• Office of Controlled Substances File No.
• Name of the pharmacy or establishment
• Street
• City
• Province
• Postal code
• Telephone number (   )
• Date (YYYY-MM-DD)
• Rx No. if filled
• Written
• Verbal
• Name of product
• Quantity & dosage form
• Name & address of the individual named on the prescription
• Practitioner (name & address)
• If the prescription was not filled, briefly describe what happened and any other pertinent information
  • Attachment
  • Yes
  • No
• For each prescription filled, name and licence number of the pharmacist who filled it. Pour chaque ordonnance executée, s.v.p. fournir le nom du pharmacien l'ayant executée ainsi que son numéro de permis d'exercice
• Name and title of reporting pharmacist or practitioner (printed)
• Licence or permit number
• Date (YYYY-MM-DD)
• Signature
• Submit to:
  Office of Controlled Substances
  &Liaison Division
  A.L. 3502B
  Ottawa, ON K1A 1B9
  Tel: (613) 954-1541 Fax: (613) 957-0110