Consumers > File a Complaint | Iowa Dental Board

Person Registering Complaint

Name of person registering complaint:

Address:

Street
Street (2)
City:		State:
Zip Code:

E-mail address: (Required)

Home Phone:

Work Phone:

Contact preference:

At home
At work
Via e-mail
No preference

Patient Information

Patient's name:

Relationship to patient:

Patient's Address:

Street
Street (2)
City:		State:
Zip Code:

Patient's E-mail address:

Patient's Home Phone:

Patient's Work Phone:

Complaint Filed Against

Name of person complaint is against:

Profession:

Dentist
Dental Hygienist
Dental Assistant
Other

Street
Street (2)
City:		State:
Zip Code:

Approximate treatment dates:

How long have you been a patient of this practitioner?

Previous dentists name

Dates with previous dentist

From	To

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

No
Yes

If yes, who did you see?

	Name	Address	Dates
1
2
3

Nature of Complaint

Select 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 (Please specify...)

Narrative

Please explain in your own words, an account of what happened:

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.

Check this box if you are ready to submit this complaint. Click the "Submit" button below to submit your complaint..