File a Complaint

Part A: Complainant Information
Part B: Patient Information ( )
Part C: Licensee Information
Part D: Complaint Information

Note: If you are filing a complaint against several licensees, you must send each one separately. To do this, complete this form, send it and then back up and fill out the information for the next licensee. The rest of the information will still be filled in.

Please provide detailed information regarding your complaint to include date(s) of treatment.