Unlicensed Medical Practice Complaint Form
Report suspected unlicensed medical practice. Please provide as much detail as possible to assist with the investigation.
Your Full Name
*
First Name
Last Name
Your Email Address
*
example@example.com
Your Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date and Time of Incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of Incident (Address or Facility Name)
*
Practitioner Name (if known)
Description of Incident
*
Witnesses (Names and Contact Information, if any)
Upload Supporting Evidence (photos, documents, etc.)
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Have you reported this incident elsewhere? If yes, please provide reference details.
Submit Complaint
Should be Empty: