Complaint Form Page 3
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1
2
3Complaint Form
Revised 7/2015
5) Please describe your complaint in detail below (use additional paper if necessary):
I certify that the above information is true to the best of my knowledge.
Signature of Complainant _________________________________ Date _______________
To submit this complaint to the Board, please print this document and mail it to the Board
at the following address:
Oregon Medical Board
st
1500 SW 1
Ave, Suite 620
Portland, OR 97201
Oregon Medical Board| 1500 SW 1st Ave, Suite 620 | Portland, Oregon | 97201
971.673.2700 or 877.254.6263 |
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