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6200 Park Ave, Ste 100 Des Moines, IA 50321


IMP3 Self-Report Form

Date of Birth


    Have you undergone an evaluation 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?

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