TMB Complaint Form

COMPLAINT REGISTERED AGAINST:

Name of Practitioner:
Address:

City, State, Zip code:  
Business phone number:

PERSON REGISTERING COMPLAINT:

Name:
Address:
City, State, Zip code:
E-Mail Address:
Verify E-Mail address:
Home phone number:
Business phone number:
Patient/Person Harmed by Practitioner:
Date of Birth (mm/dd/yyyy)

DETAILS OF COMPLAINT:

1. Describe your complaint in detail and the events that led to your complaint. 
    Include dates and location of treatment, medications prescribed.

 2. Have you received a second opinion from another physician? Yes No

If so, please give: Name of Physician:  
Physician's Address:

I have read the preceding, and it is true to the best of my information and belief. I understand that if I do not provide a name or a source this complaint will not be processed.

If my complaint would be more appropriately addressed by a different agency or society, I authorize TMB to forward my complaint to that agency or society.