TPP Alberta Forgery Reporting Form - College of Physicians & Surgeons of Alberta

Incident details:

Incident date (should be typed in the format mm/dd/yyyy, as in 03/15/2023):*

Incident location:*

I.e. pharmacy name

Date forgery was discovered:

Same as incident date

Select a date, if different than the incident date listed above (should be typed in the format mm/dd/yyyy, as in 03/15/2023):*

Was the pharmacy (or pharmacies) involved informed about the incident?*

Yes
No

Was the forged prescription dispensed?*

Yes
No

If you know the dispense date, please include it (the date should be typed in the format mm/dd/yyyy, as in 03/15/2023):

Forgery details:

The forgery involved the use of:*

Please check all that apply.

Computerized/EMR prescription
Regular prescription pad
Lost/Stolen prescription pad
Verbal order/impersonation
TPP form
Faxed order
Other

If other, please describe:*

Drug information:*

Drug name	Strength	Quantities

Individual/recipient named on the forged document:*

First name	Last name	DOB	ULI/Out of province healthcare number:	Is the person suspected of forgery known to the clinic? Yes or no

Prescriber's name:*

First Last

Prescriber's regulated information:*

Profession	License number

Clinic Address:*

Phone:*

Fax:*

Please attach a copy of the forged document and any other supporting documents you wish to include in your report.

Drop files here or

Accepted file types: pdf, jpg, png, Max. file size: 5 MB.

Individual reporting the forgery

Who is reporting this forgery?*

Same prescriber as above
Prescriber's delegate

Delegate information:*

Name	Title

Preferred contact information:

Email
Phone
Fax

Email*

Enter Email Confirm Email

Phone/Fax*

Additional comments

Visit the TPP Alberta website to see TPP forgery FAQs or the ACP website to see FAQs for pharmacists.

Phone

This field is for validation purposes and should be left unchanged.

Incident details:

Forgery details:

Individual reporting the forgery

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