Form 071-61 - Consumer Comp[liant Form - Medical Board Of California Page 3
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4COMPLAINT REGISTERED AGAINST
I wish to file a complaint against the individual named below. I understand that the Medical Board does not
assist citizens seeking return of their money or other personal remedies. I am, however, submitting this
information so that it may be determined whether disciplinary action against this practitioner’s license should be
considered.
Physician (M.D.)
Podiatrist (DPM)
Physician Assistant (PA)
Midwife
Check one:
Polysomnographer
Research Psychoanalyst
Unlicensed Provider
Name:
(Last Name)
(First Name)
(Middle Initial)
Office/Facility Name:
License Number
:
(if known)
Address:
(Street)
(City)
(State)
(Zip Code)
Phone Number:
Has the patient been examined/treated by another professional for this same condition?
No
Yes
If yes, provide name and address on the Authorization for Release of Medical Information.
Reason for Treatment:
Date(s) of Treatment:
DETAILS OF COMPLAINT
(Attach additional sheets if necessary)
07I-61 (Revised 9/2017)
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