Complaint Form - Maryland Board Of Physical Therapy Examiners Page 2
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3THERAPIST / BUSINESS
(Complained About)
Therapist / Business Name
Address
City, State Zip
Telephone
Dates of Service
From
To
Have you discussed your complaint with the PT or PTA about whom you are making the complaint?
Yes
No
If yes, what was their response?
WITNESSES
State the names, and if known, addresses and telephone numbers of all persons, including PT’s or PTA’s who witnessed or who have
any knowledge of your complaint or this occurrence. Also include any person (s) who assisted you in investigating this issue. If more
room is needed please include it on a separate sheet of paper.
#1
#2
Name
Name
Address
Address
City, State Zip
City, State Zip
Telephone #
Telephone #
#3
#4
Name
Name
Address
Address
City, State Zip
City, State Zip
Telephone #
Telephone #
#5
#6
Name
Name
Address
Address
City, State Zip
City, State Zip
Telephone #
Telephone #
MEDICAL TREATMENT
If you received medical treatment for the issue you are receiving physical therapy for please provide the following information.
Doctor’s Name
Hospital Name
Address
Address
City, State Zip
City, State Zip
Telephone #
Telephone #
Dates of Service:
From
To
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