Dental Board
  • Fields marked by a * are required.

  • If you see the icon next to the field, you can click on the box to see a list of available choices or you can type your own text directly into the box. When you are done entering all fields, click Continue.

  • If you have any supporting information, you may attach it to your complaint by using the Attachment button at the bottom of the page.

Person Filing Complaint

Complainant Name
Complainant Address Line 1
Complainant Address Line 2
Complainant City
Complainant State
Complainant Zip
Complainant Date of Birth
Complainant Gender
Complainant E-mail
Complainant Phone
Complainant Phone Type
Complainant Phone 2
Complainant Phone 2 Type
Complainant Phone 3
Complainant Phone 3 Type
Preferred Method of Contact
Relationship to Patient

Patient Information

Patient Information Same as Complainant Yes No
Patient Name
Patient Address Line 1
Patient Address Line 2
Patient City
Patient State
Patient Zip
Patient Phone Number
Patient Date of Birth
Patient Gender
Patient 2 Name
Patient 2 Address Line 1
Patient 2 Address Line 2
Patient 2 City
Patient 2 State
Patient 2 Zip
Patient 2 Phone Number
Patient 2 Date of Birth
Patient 2 Gender
Patient 3 Name
Patient 3 Address Line 1
Patient 3 Address Line 2
Patient 3 City
Patient 3 State
Patient 3 Zip
Patient 3 Phone Number
Patient 3 Date of Birth
Patient 3 Gender
Patient 4 Name
Patient 4 Address Line 1
Patient 4 Address Line 2
Patient 4 City
Patient 4 State
Patient 4 Zip
Patient 4 Phone Number
Patient 4 Date of Birth
Patient 4 Gender

Complaint Filed Against

Dental Practitioner's Name / Name of Practice *
Name of practice
Address of practice
City of practice
State of practice
Zip Code of practice
Phone number of practice
Nature of Complaint #1 *
Nature of Complaint #2
Nature of Complaint #3
Other
How long have you been a patient?
Have you seen another practitioner about the issue? If yes, provide name below Yes No
Have you discussed this matter with the practitioner? Yes No
If yes, please provide details
Have you contacted an attorney or other agency about the issue? Yes No
If yes, please provide details
Do you have a professional or business relationship with the practitioner? Yes No
If yes, please provide details
What would you like to see occur to resolve this issue?
Other practitioner 1
Other practitioner 1 Address Line 1
Other practitioner 1 Address Line 2
Other practitioner 1 City
Other practitioner 1 State
Other practitioner 1 Zip
Other practitioner 2
Other practitioner 2 Address Line 1
Other practitioner 2 Address Line 2
Other practitioner 2 City
Other practitioner 2 State
Other practitioner 2 Zip

Complaint Description

Complaint Narrative (Use attachment function below if more than 2000 characters)

Attachment

Attachment: Description: