Complaint Submission — Clinic Management

About you

Person submitting the complaint

Title

Relationship to patient *

First name *

Last name *

Email address *

We will use this email for updates.

Verify email address *

Re-enter the same email to confirm.

Phone number

Address line 1 *

Address line 2

City *

State *

Postal code *

Patient / person harmed

Who was affected by this issue

Full name *

Date of birth *

Use format mm/dd/yyyy

Complaint against

Who or what this complaint is about

Name of complainee *

Role of complainee *

What happened

Share details that help us investigate

Complaint category *

Detailed description *

Be as specific as you can — dates and locations help a lot.

0 / 10000

Do you have supporting documents?

Thanks — after review, Compliance will email instructions for sending records, photos, or links.

Did you receive a second opinion?

Second opinion provider details

Practitioner name

Phone number

Email address

Declarations

Confirm each statement to continue

I agree that I have read and understood the Citizen Complaint Process document.

I agree that while my confidentiality, unless waived, will be strictly safeguarded, I may not be anonymous to the Board and that I may be contacted by staff of the Board for additional information during the course of any investigation.

I agree that once my complaint is submitted, I may not withdraw it.

I agree that if additional information is required or if my testimony is required that I will cooperate with these requests. I understand that if I do not cooperate, it may result in my complaint being dismissed due to lack of cooperation.

I agree that updates on my complaint may be provided by email instead of postal service.

Your submission is sent securely to the Compliance Officer.
You can scroll back anytime to edit before submitting.