Complaint Form Leave this field blank indicates required field Name of Person Making Complaint Pre: Mr Ms Mrs Mr. & Mrs. Dr First Name: Middle Name: Last Name: Mailing Address: City State Zipcode Daytime Phone Number: Your Email Address: Verify Email Address: Patient's Full Name (if different from complainant) First Name: Middle Name: Last Name: Date of Birth: Relationship to Patient: Information about the PHYSICIAN (MD, DO) or PHYSICIAN ASSISTANT you are reporting (not a practice or hospital name) Licensee's First Name: Middle Name: Licensee's Last Name: Licensee's Practice Address: City State Zipcode Licensee's Telephone #: Complaint It is recommended that you compose your complaint statement as a document and save it to your computer. You may cut and paste the text of your statement into the space below, or send your statement as an attachment. This will provide you with a written record of your complaint and prevent the loss of your statement in the event of technical difficulties with this form. How did you hear about the NC Medical Board? Friend/family Physician Attorney Pharmacist Other Agency Other Healthcare Professional Internet Other Please specify… Complaint: When did this event occur? Please list specific dates of service. Where did this event occur? Please list full name of practice or hospital. Have you contacted the licensee about your concerns? If yes, what was the licensee's response? What would you consider to be a fair resolution to your complaint? (The Board cannot assist with compensation) Attachments (medical records, correspondence, etc.) Attachment 1 Attachment 2 You will receive an auto reply to the email entered above. If you do not receive this email, your submission was not received. You may contact the Complaint Department if you have any issues or questions.