Consumer Complaint Form
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3BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GOVERNOR EDMUND G. BROWN JR.
a Dental Board of California
2005 Evergreen Street, Suite 1550, Sacramento, California 95815
P (916) 263-2300 | F (916) 263-0873 |
CONSUMER COMPLAINT FORM
PLEASE PRINT OR TYPE
COMPLAINT REGISTERED AGAINST
Name of Dental Office:
Name:
Address:
City:
State:
Zip Code:
Office Phone Number:
PERSON REGISTERING COMPLAINT
Mr.
Relationship to Patient:
Name:
Mrs.
Ms.
Home Phone Number:
Addre ss:
Work Phone Number:
City:
State:
Zip Code:
Male
Patient’s Date of Birth:
Female
Patient Name:
Legal authority to act on patient’s behalf?
Has patient been examined or treated by another dentist for this same compliant?
YES
NO
If yes, please provide full names and addresses on the back of this form.
DESIRED OUTCOME OF THIS COMPLAINT
DETAILS OF COMPLAINT
Dates of Visits:
State your complaint in detail:
D
NOTICE: As much information as possible should be provided, in addition to any supporting documents
DO NOT WRITE IN
pertaining to your specific complaint. Failure to provide sufficient information or documentation may
THIS SPACE
prevent or delay the review of your complaint. The information will be used to determine whether a violation
of law has occurred. If a violation is substantiated, the information may be transmitted to other
governmental agencies, including the Attorney General’s Office. The Dental Board of California does not
have jurisdiction over fee disputes or office business procedures.
Signature________________________________________
Date____________________
ENF-10 (03/01)
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