Instructions for Completing the Consumer Complaint Form

1. Please print or type all information.
2. Provide the full name and address of the person your complaint is against. It is important to identify the Hygienist, Hygienist in Alternate Practice (HAP), or Hygienist in Extended Functions(HEF) who provided the treatment you are complaining about. Please obtain the name of the treating hygienist prior to filing this complaint. The complaint cannot be filed against a company or clinic unless it concerns unsafe or unsanitary conditions.
3. Provide the full name and address of all subsequent treating hygienists. This should be provided on the form.
4. Please state your complaint in chronological order, in detail, and include dates of treatment, if known. It is important to be specific regarding allegations of substandard care. Failing to completely describe your complaint or fill out all necessary documents may result in unnecessary delays in our review.
5. Please attach a copy of any supporting documents you may have in your possession pertaining to your specific complaint.
6. Please sign the Authorization for Release of Dental/Medical Patient Records.
7. Please return the completed forms to the Hygiene Board.

Note: The Authorization for Release of Dental/Medical Patient Records must be signed in order for the Board to process your complaint.