Please provide the following information so that we may acknowledge receipt of your complaint and that we may contact you should we need further information.
Required*
Name*
Address*
City*
State*
Zip Code*
Daytime Phone*
Patient's Name*
Email* (Needed for confirmation email)
Is the provider a Select Dentist Denturist Dental Hygienist Dental Radiographer
Please provide information about your complaint including dates, names and addresses of other persons who may be involved.