Dental Complaint Form Page 2
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3DPH Date Rec’d (stamp)
DENTAL
DEPARTMENT OF PUBLIC HEALTH
COMPLAINT
FORM
BUREAU OF HEALTH PROFESSIONS LICENSURE
TEL (617) 973-0865
FAX (617) 973-0985
TTY (617) 973-0988
DPH USE ONLY:
_____
Entered into Database (date) ______/______/_____
Complaint # ________________________
Initials
Please complete this form as fully as possible. Please TYPE or WRITE LEGIBLY in ink.
Mr.
Mrs.
Ms. __________________________ ________________________ ______________________________________
Patient’s Name
Your Last Name
Your First Name
(If different)
Your Business Name: _______________________________________________________________________________
(if applicable)
Business Address: _____________________________________ __________________________ ______ _________
Street
City
State
Zip
Your Address: ________________________________________ ___________________________ ______ _________
Street
City
State
Zip
Your Primary
Your Secondary
Your
Phone number: (
)
Phone number: (
)
Email:
DO NOT LIST A DENTAL CLINIC OR DENTAL CENTER ON THIS LINE
DENTIST
DENTAL HYGIENIST
DENTAL ASSISTANT
______________________________________ _____________________________
______________
Last Name
First Name
Lic # (if known)
Licensee’s Business Name: _________________________________________________________________________
Business Address: __________________________
__________________
_______
________
_____________
Street
City
State
Zip
Phone
PREVIOUS DENTIST (if applicable) ________________________________________________________________
Name
________________________________________________________________________
__________________
Street and City Address
Phone
SUBSEQUENT DENTIST* (if applicable) ____________________________________________________________
Name
________________________________________________________________________
__________________
Street and City Address
Phone
* Attach report from subsequent dentist (if available).
Have you discussed this matter with the dentist/hygienist/dental assistant or anyone in the licensee’s office?
yes
no
Date of contact: ____________________ How was contact made? (phone, e-mail, letter, in person) _________________
Result of contact ___________________________________________________________________________________
_________________________________________________________________________________________________
Witness name(s) and telephone number(s) (if applicable) ___________________________________________________
Have you filed this complaint with any other state or federal agencies? _____ If yes, explain____________________
________________________________________________________________________________________________
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Parent category: Medical