Complaint Form 

You may use this form to provide your complaint information and summary. Be as concise as possible. When completed, please click the "Submit Form" button at the bottom of the page to submit your form electronically.  If you have documents to support your allegation(s), please email them to the Board at shendricks@medboard.nv.gov, and include in the email your name and the date you submitted your Complaint Form.  If you wish to submit your form and supporting documentation via mail or fax, please use the PDF version of the Complaint Form and mail or fax to the address/fax number on the form.

Complainant Contact Information

Name: 

Gender:                     Phone Number:  

Mailing Address:

City:     State:     Zip Code: 

Patient Information

Name:

Gender:

Date of Birth: 

Health Care Professional Information

First Health Care Professional

Name:

Address:
 

City:      State:     Zip Code: 

Phone Number: 

Second Health Care Professional

Name:

Address:
 

City:     State:     Zip Code: 

Phone Number: 

Third Health Care Professional

Name:

Address:
 

City:     State:     Zip Code: 

Phone Number: 

Incident Information

Date(s) of Occurrence:

Treatment Received at (please check the following that apply, and include name and address):

Did you obtain a second opinion from another physician?     

If "yes":

Name of Physician:

Physician Address:
 

Diagnosis:
 

Complaint Summary

 By checking this box, I hereby attest that the information contained in this Complaint is true and correct to the best of my knowledge and belief.

Date: 

 

                         

 

 

 

Last date edited: 9/21/2017