Complaint No.: ___________________
(For Official Use Only)     

OFFICIAL COMPLAINT FORM

RETURN TO:

201 N.E. 38th Terrace · Suite 3 · Oklahoma City · Oklahoma 73105

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Complaint Against (Doctor's Name)

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Street Address                                                                                    Street Address (Person filing complaint)

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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)

The doctor did NOT explain the intention and goal of the treatment.                                 

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With this form, the above information is presented as a formal complaint.

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Signature of Person Filing Complaint · Date                                 Please PRINT Name of Person Filing Complaint

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Signature of Witness · Date                                                              PRINT Name of Witness

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Signature of Notary · Date                                                               Date of Notary Commission Expires