Intake Form

Person Supplying Information

Submit Anonymously

First Name	Middle Initial	Last Name
Business Name (If Applicable)
Address 1
Address 2

City

State

Zip Code

Home Phone	Work Phone	Fax Number
Email Address
Relationship to the Practitioner (Not Specified) Patient/Client Patient/Client's Relative/Friend Co-Worker Supervisor Other (Specify)

Subject of Report (Practitioner or Facililty you wish to complain about)

NOTE: If you would like to complain about more than one practitioner, you will need to submit a separate complaint form for each individual/entity you would like to complain about.

Title Dr. Mr. Ms.	First Name *	Middle Initial	Last Name *	Gender Unknown Unknown Female Male

License Type (e.g. M.D., RN, DDS, etc.)	License Number
Business or Facility Name (If Applicable)
Address 1
Address 2

City

State

Zip Code

Home Phone	Work Phone	Fax Number
Email Address
Note: Asterisk (*) signifies a required field. Put N/A if the field does not apply or if you are unable to answer any required field. If filing on a facility regulated by DHP (e.g. pharmacy, veterinary establishment, funeral establishment) answer N/A for first and last name and type the name of the facility into the Business Name field.

Please provide specific information when completing the details requested below. Failure to provide specific information will limit the department's ability to investigate your concerns.

Patient Information

Same As Person Supplying Information above.

No Patient Information

First Name *	Middle Initial	Last Name *

Date of Birth (M/d/yyyy)

Address 1

Address 2

City

State

Zip Code

Home Phone	Work Phone	Fax Number
Email Address
Note: At least some of this information must be filled in or we cannot verify your complaint.

Details of Report

* What did the practitioner do or fail to do? Include specific details: Who, What, Where, When. Characters Remaining: 4000
Should the space below be insufficient to hold the details of your complaint, there will be an opportunity to add attachments on a later page.

Note: Asterisk (*) signifies a required field.

The Patient/Client sustained injury or harm as a result of the licensee's Actions.

I have contacted the Licensee regarding my concerns.

My concern or incident is related to a facility, private office, home, etc.

Who else has knowledge of these events? Please provide full names and contact information. Characters Remaining: 2000

I have reported this complaint to another agency or court.