EmailMe Form - Consumer Complaint Form

Your Name: *
Prefix First Last Suffix
Your Mailing Address: *

Street Address City State / Province / Region Postal / Zip Code
Your Contact Phone Number:
### - ### - ####
Your Email Address:
Name of the dentist you are complaining against: *
We cannot proceed with an investigation without the specific name of the dentist you are complaining against. Please do not list the name of the dental practice/corporation.
Nature of complaint: *
Dissatisfied with treatment
Monetary/Billing/Insurance
Infection Control
Patient Abandonment
Child Maltreatment
Your view as to a fair resolution of this matter: *
Note: Recovery of money (refund, damages, etc.) is outside of the Board's jurisdiction.
Explain the circumstances surrounding your complaint (what prompted a complaint about the dentist?): *
File Upload (if you have any photos or other supporting documentation that you'd like to attach to your complaint):

Add File
Do you agree to the Terms and Conditions? *
Yes
Click above if you have read and agree to the Terms and Conditions. The terms and conditions can be found on the "Consumers" tab of the Board's website.
Signature (please type your name):
Date Submitted: *
MM / DD / YYYY