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Get TX TBCE Complaint Form

: Business Phone Number: PERSON REGISTERING COMPLAINT *See Guide Name: Address: City: State: Home Phone: Business Phone: Zip Code: E-Mail: PATIENT/PERSON HARMED BY THE PRACTITIONER: Name: Date of Birth (m/d/yyyy): LOCATION WHERE COMPLAINT OR VIOLATION OCCURRED Address: City: County: State: Zip Code: Details of Complaint: Describe your complaint in detail and the events that led to your complaint. Include dates and location of treatment, therapies prescribed or utilized. You may use add.

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