Texas Medical Board

NOTICE:

IF IT IS DETERMINED THE INDIVIDUAL OR PRACTICE IDENTIFIED IN YOUR COMPLAINT IS NOT REGULATED BY THE TEXAS MEDICAL BOARD THAT INFORMATION, INCLUDING YOUR IDENTITY, MUST BE PROVIDED TO THE PROPER AGENCY FOR INVESTIGATION. YOUR COMPLAINT AND ALL THE INFORMATION PROVIDED, INCLUDING YOUR IDENTITY, REMAINS CONFIDENTIAL WHEN REFERRED TO ANOTHER AGENCY.

COMPLAINT REGISTERED AGAINST:

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.