Name of Practitioner *

Address *

City *

State *

Zip code *

Business phone number *

PERSON REGISTERING COMPLAINT:

First Name *

Last 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. (* required)

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.