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On-line Complaint Form (WV Code 14-4-5)

Please fill in the following form to process your complaint on-line. Upon submitting this form, additional instructions will be provided for including supporting documents.

1. If you are a human, leave this field blank.

2. 1. Complaint is filed against:

3. * Name:
4. * Phone:
5. * Street Address:
6. * City:
7. * State: Choose State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
8. * Zip Code:
9. * Date of Care: (dd/mm/yyyy)

1. 2. Person filing complaint (complainant):

2. * Name:
3. * Phone:
4. * Email:
5. * Street Address:
6. * City:
7. * State: Choose State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
8. * Zip Code:

1. 3. Complainant's relationship with the person against whom complaint is being filed:

2. Relationship:

1. 4. Summary of complaint:

1. 5. Other persons with knowledge of incident(s) giving rise to this complaint. (Include any practitioner or institution giving follow-up care.)

2. Name:
3. Phone:
4. Address:
5.  
6. Name:
7. Phone:
8. Address:

1. 6. State in your own words how this incident(s) relates to the West Virginia Board of Optometry Jurisdiction.

1. 7. Have you advised any other regulatory or legal authority of this complaint, i.e.: the Attorney General's office?

1. 8. What action, if any, are you seeking from the Board?

1.       * I agree that all information is accurate to the best of my knowledge.
2. * Todays Date: (dd/mm/yyyy)
3. * required fields