This complaint cannot be processed without the full name of the physician or acupuncturist. Please verify spelling.
Photocopies are acceptable.
Failure to complete and sign this release may prevent investigation of your complaint. Please list the names and addresses of all healthcare providers and institutions that provided treatment which may relate to this complaint. If you need more space, continue on reverse or on another sheet of paper . The information in this complaint is true, correct and complete to the best of my knowledge.