Complaint Form

Optometrist Complaint Form

INSTRUCTIONS:

Please state clearly and specifically all allegations against person named below. List each incident, specific date(s), full name of patient, and a brief statement describing each incident. Attach copies of any documents you have concerning the allegation. Please complete the entire form.

PERSON MAKING ALLEGATION:

Name

Address

City

State

Zip Code

Phone

PERSON AGAINST WHOM ALLEGATION IS MADE:

Optometrist Name

Optometrist Practice Address

Optometrist Practice City

State

Zip Code

Brief Outline of Allegation or upload documentation

File Upload

I acknowledge that the Kansas State Board of Examiners in Optometry may provide a copy of this form to the above named person against whom this allegation is made, I agree to testify in any hearings which may arise as a result of this allegation. The statements I have made are true and correct to the best of my knowledge and belief.

Name

Date

RELEASE OF INFORMATION AUTHORIZATION

I hereby authorize all hospitals, institutions, optometrists, physicians, clinics, employers (past and present), laboratories, insurance companies, and/or all government agencies to release to the KS State Board of Examiners in Optometry or its representatives any and all information, records, files or documents in whatever form pertaining to information in their possession or control.

Patent Name

Signed By

Date

Parent/Guardian if applicable

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