|
Complaint No.: ___________________ OFFICIAL COMPLAINT FORM ___________________________________ Date(s) of Service:_____________________
Complaint Against (Doctor's Name)
___________________________________ ____________________________________
Street Address Street Address (Person filing complaint)
___________________________________ ____________________________________
City State Zip City State Zip
Phone Number(s) where you can be reached:
Home: _____________________________
Work: ______________________________
Description of Complaint
(If further writing space is needed, please attach additional pages to the form)
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
With this form, the above information is presented as a formal complaint.
__________________________________________ _______________________________________________
Signature of Person Filing Complaint · Date Please PRINT Name of Person Filing Complaint
__________________________________________ _______________________________________________
Signature of Witness · Date PRINT Name of Witness
__________________________________________ _______________________________________________
Signature of Notary · Date Date of Notary Commission Expires
|