COMPLAINANT INFORMATION (Person filing complaint):
COMPLAINT REGISTERED AGAINST:
State your complaint and include details of events, dates, witnesses
(with telephone numbers and addresses) and any pertinent documentation. Press Send at the bottom once you have completed this form.
If you need assistance in completing this form, call the Board office at:
In Order to insure procedural due process, it may be necessary that your name will be disclosed to the practitioner or facility/institution in question
YOUR COMPLAINT IS A MATTER OF PUBLIC RECORD