Follow the steps to accurately complete your complaint form.

1. Click ‘Get Form’ button to access the complaint form and open it in the editor.
2. Begin by entering the information of the individual dentist, dental hygienist, or healthcare worker against whom you are filing the complaint. Provide their full first and last name, office name, office phone number, and office address including city, state, and zip code.
3. Now, fill in your own personal information as the person registering the complaint. Include your first name, last name, address, city, phone number(s), and email.
4. If applicable, provide information about the patient involved in the complaint. This includes the patient's last name, first name, date of birth, and relationship to the patient.
5. Indicate the type of complaint by selecting the relevant options from the list (e.g., crowns, dentures, misdiagnosis, etc.). You can check multiple boxes as necessary.
6. In the 'Complaint Details' section, provide a detailed description of your complaint. Use additional pages if necessary to ensure clarity.
7. If there are any witnesses who can support your claim, please provide their first name, last name, phone number, and email address.
8. If the patient has consulted another dentist for the same issue, document their full names and addresses.
9. Specify the desired outcome of your complaint. Be clear about what resolution you are seeking.
10. Indicate any other state board or agency you have notified about this incident.
11. Complete the ‘Release of Information’ section by authorizing the release of relevant medical and dental records necessary for the investigation. Ensure to include your signature and date of signing.
12. Once all sections are filled out, review your form for accuracy before saving changes, and consider downloading or printing a copy for your records.

Get started on your complaint form today and ensure your voice is heard.