Complaint Form

Name of person complaint is against:  

Profession:    Dentist     Dental Hygienist   
 Dental Assistant   Other

Address  City  
State    ZIP Code  

Approximate treatment dates:

How long have you been a patient of this practitioner?

Previous dentists name  from  to 

Have you seen any other practitioners in connection with this complaint?

If yes, who:

Name:     Name:  
Address    Address   
Dates:                Dates:     

  
  Please check all that apply:

 Poor dental treatment                     
  Refusal to tranfer dental records
 Ethical                                           
 Practicing under the influence of drugs and/or alcohol
 Fee dispute                                    
 Billing for services not rendered
 Competency                                  
 Other  
  

Below, please explain in your own words, an account of what happened.

  Narrative:
 
  

I certify that the information given herein is true and correct to the best of my knowledge. With the submission of this electronic form, I authorize the release of my dental records, when necessary, from any treating practitioner to the Iowa Dental Board and its agents for investigative purposes. If this complaint involves a minor, this release authorizes the release of the minor's dental records, when necessary, to the same.