400 SW 8th St, Suite E
Des Moines, IA 50309-4688
Have you undergone an evaluations for this condition?
Have you received any treatment for this condition?
Who was your treating medical provider?
Have you engaged in unlawful diversion or distribution of controlled or illegal substances for personal gain or profit?
Are you currently under a Board of Pharmacy Order for alcohol and/or drug abuse or for another issue related to impairment?
Have you caused harm and/or injury to a patient?
Is the Board of Pharmacy currently investigating you for matters related to impairment?
Have you provided inaccurate, misleading, or fraudulent information or failed to cooperate with the Board of Pharmacy or IMP3?
All information is confidential. Do you give permission to inquire about the material facts provided in this self-report?