Consumer Complaint Form
Please complete the form, being as detailed as possible.
Your Mailing Address:
State / Province / Region
Postal / Zip Code
Name of the dentist you are complaining against:
We cannot proceed with an investigation without the specific name of the dentist you are complaining against. Please do not list the name of the dental practice/corporation.
Nature of complaint:
Dissatisfied with treatment
Your view as to a fair resolution of this matter:
Note: Recovery of money (refund, damages, etc.) is outside of the Board's jurisdiction.
Explain the circumstances surrounding your complaint (what prompted a complaint about the dentist?):
File Upload (if you have any photos or other supporting documentation that you'd like to attach to your complaint):
Do you agree to the Terms and Conditions?
Click above if you have read and agree to the Terms and Conditions. The terms and conditions can be found on the "Consumers" tab of the Board's website.
Signature (please type your name):