GEORGIA BOARD OF DENTISTRY COMPLAINT FORM
GEORGIA BOARD OF DENTISTRY
COMPLAINT FORM
TYPE OR PRINT LEGIBLY AND MAIL TO THE ADDRESS LISTED BELOW
NOTE: The Georgia Board of Dentistry DOES NOT have authority over dental groups, practices, clinics
or offices. Therefore, you must provide the full name of the individual dentist and/or hygienist- please do
not list dental groups, practices, offices or clinics. Please keep a copy of this complaint information for
your records. Once it is processed by the Board, it is confidential and cannot be provided back to you.
1. FULL NAME OF DENTIST/DENTAL HYGIENIST AGAINST WHOM YOU ARE
FILING THE COMPLAINT:
(FIRST & LAST)
ADDRESS (STREET)
(CITY, STATE, ZIP CODE)
TELEPHONE NUMBER (
)
LICENSE # (IF KNOWN)
2. COMPLAINANT¡¯S NAME
(FIRST, MIDDLE INITIAL, LAST)
DATE OF BIRTH
(MM/DD/YYYY)
OTHER NAMES EVER USED
ADDRESS (STREET)
2 Peachtree St., NW, 36th Floor ¡ñ Atlanta, Georgia 30303 ¡ñ (404) 651-8000 ¡ñ (678) 717-6694 FAX
gbd.
(CITY, STATE, ZIP CODE)
E-MAIL ADDRESS: _____________________________________________________________
PHONE NUMBERS
MALE / FEMALE
(Please circle one)
(
)
(BUSINESS)
(
_)
(HOME)
(
)
(CELL)
3. PATIENT¡¯S NAME (If different from complainant)
DATE OF BIRTH
______________________________________________________________________________
(FIRST, MIDDLE INITIAL, LAST)
(MM/DD/YYYY)
ADDRESS (STREET) (If different from complainant)
(CITY, STATE, ZIP CODE)
PHONE NUMBER (If different from complainant)
MALE / FEMALE
(Please circle one)
(
)
(BUSINESS)
(
_)
(HOME)
(
)
(CELL)
4. NAME OF ADDITIONAL DENTIST/DENTAL HYGIENIST AGAINST
WHOM YOU ARE FILING THE COMPLAINT:
NAME (FIRST & LAST)
ADDRESS (STREET)
(CITY, STATE, ZIP CODE)
PHONE NUMBER (
)
2 Peachtree St., NW, 36th Floor ¡ñ Atlanta, Georgia 30303 ¡ñ (404) 651-8000 ¡ñ (678) 717-6694 FAX
gbd.
LICENSE # (IF KNOWN)
5. ALLEGATION AND APPROXIMATE DATE(S) OF VIOLATION(S)
Please check box(es) below which describe the nature of your complaint.
?
?
?
?
?
?
?
?
?
?
?
QUALITY OF CARE
MISDIAGNOSIS OF CONDITION
UNPROFESSIONAL CONDUCT
UNSANITARY CONDITIONS
PATIENT ABANDONMENT
RECORDS RELEASE
Note: If your complaint is based on failure to release patient records, you MUST
submit a written request to the dentist and give him/her a reasonable amount of time
to respond to your request. Georgia law (O.C.G.A. ¡ì31-33) allows the dentist to
charge a reasonable fee for copying your records. You must include with this
complaint a copy of a signed, certified mail return receipt, or any other document,
showing that the provider received your request.
INSURANCE FRAUD
SUBSTANCE ABUSE
UNLICENSED PRACTICE
OTHER
APPROXIMATE DATE(S) OF VIOLATION:______________________________
6. PLEASE PROVIDE A CLEAR AND CONCISE DESCRIPTION OF THE
INCIDENT OR NATURE OF YOUR COMPLAINT. Please include the date(s)
and any other person(s) involved in this matter; attach COPIES of any relevant
documents that you may have. (Attach copies only ¨C these materials will not be
returned.)
2 Peachtree St., NW, 36th Floor ¡ñ Atlanta, Georgia 30303 ¡ñ (404) 651-8000 ¡ñ (678) 717-6694 FAX
gbd.
7. HAVE YOU SEEN ANOTHER DENTIST(S) CONCERNING THIS ISSUE? IF
SO, PLEASE PROVIDE THE FOLLOWING INFORMATION:
NAME OF PRIOR and/or SUBSEQUENT DENTIST/DENTAL HYGIENIST
(FIRST AND LAST)
ADDRESS (STREET)
(CITY, STATE, ZIP CODE)
PHONE NUMBER (
)
LICENSE # (IF KNOWN)
NAME OF PRIOR and/or SUBSEQUENT DENTIST/DENTAL HYGIENIST
(FIRST AND LAST)
ADDRESS (STREET)
(CITY, STATE, ZIP CODE)
TELEPHONE NUMBER (
)
LICENSE # (IF KNOWN)
NAME OF PRIOR and/or SUBSEQUENT DENTIST/DENTAL HYGIENIST
(FIRST AND LAST)
ADDRESS (STREET)
(CITY, STATE, ZIP CODE)
TELEPHONE NUMBER (
LICENSE # (IF KNOWN)
)
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- complaint form please type or print legibly in
- new jersey office of the attorney general
- filing a complaint with the state board of dentistry
- recognizing dental patients who are victims of domestic
- dental board of california consumer complaint form
- guide to making a complaint about medical treatment
- how to respond to a patient complaint against a dentist
- georgia board of dentistry complaint form
- north carolina state board of dental examiners
Related searches
- nevada board of dentistry license lookup
- board of education complaint line
- georgia board of medicine license lookup
- georgia board of veterinary examiners
- board of dentistry new york
- nevada board of dentistry complaints
- georgia board of nursing license renewal
- georgia board of nursing renewal
- georgia board of nursing renewal requirements
- georgia board of nursing verification
- tn board of dentistry license verification
- georgia board of nurse practitioners