Name of Practitioner *
Zip code *
Business phone number *
First Name *
Last name *
E-Mail Address *
Verify E-Mail address *
Home phone number *
Business phone number
Patient/Person Harmed by Practitioner *
Date of Birth (mm/dd/yyyy) *
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:
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.