Complaint No.: ___________________
(For Official Use Only)     

OFFICIAL COMPLAINT FORM

RETURN TO:

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

___________________________________                                       Date(s) of Service:_____________________
Complaint Against (Doctor's Name)

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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)

The doctor failed to allow for informed consent regarding the dangers of manipulation  

to the neck's upper cervical region:_____________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

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