Complaints
Complaints

Consumer Complaint Form

Please use one form for each person you are reporting. To report on multiple nurses, please enter the details again into a fresh form after submitting the previous complaint.

Nurse and Complaint Details

Nurse's Name:*

Nurse's License Type:

LPN

CRNP

CRNA

CNM

CNS

Nurse's License:

Your relationship to the nurse:

Date of birth of patient:

Explain what happened:*

(including what, when, and where)

Name, address, and phone of any witnesses:

Did you report this to anyone else?:

Yes

Hospital administration, physician, law enforcement, etc

Where does the nurse work?:

City:

State:

Your Details

Name:

Address:

City:

State:

Zip:

Invalid value

Email:

Invalid value

Phone:

Invalid value

Submit Complaint