COMPLAINT
REGISTERED AGAINST:
Name
of Practitioner:
Address:
City,
State
Business
phone number:
PERSON
REGISTERING COMPLAINT:
Name:
Address:
City,
State, Zip code
Home
Phone:
Business
Phone:
E-Mail:
PATIENT/PERSON
HARMED BY THE PRACTITIONER:
Name:
Date
of Birth (mm/dd/yyyy):
DETAILS
OF COMPLAINT:
-
Describe
your complaint in detail and the events that led to your complaint.
Include dates and location of treatment, medications prescribed.
You may use additional paper and/or provide other documents to
clarify the information given.
-
Have
you received a second opinion from another physician? ___yes ___no
If yes, please give full name and address.
I
have read the preceding, and it is true to the best of my information
and belief.
If
my compleint would be more appropriately addressed by a different
agency or society, I authorize TMB to forward my complaint to that
agency or society.
___________________________
__________________
Signature
Date
|
