COMPLAINT REPORTING FORM

COMPLAINT REPORTING FORMdtadmin2020-04-09T15:58:33+00:00

Complaint Reporting Form

Contact Information of the Person Making the Complaint:
Full Name*
Address*
Street Address City Postal Code
Telephone (Home)*
Business*
Email*
Are you the Patient who Received the Optometric Service?*
- Yes
- No, I am making this complaint on behalf of someone else
Patient Information
Full Name*
Address*
Street Address City Postal Code
Telephone (Home)*
Business
Contact Information of the Optometrist
Full Name*
Address*
Street Address City Postal Code
Provide a Clear Description of the Complaint about the Optometrist Including Relevant Dates. List and Attach any Documentation (if Applicable) Pertaining to your Complaint.*
Document Pertaining to your Complaint
Max. file size: 64 MB.