Should you have technical difficulty submitting from this site, you may contact us with details or you may use the printable form available here.Email: enfcomplaints@dhp.virginia.gov
 
Person Supplying Information



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


Subject of Report (Practitioner)

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
First Name
*
Middle Initial
Last Name
*
Gender
Unknown
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

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:
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.







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