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.

?

?

?

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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)

)

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