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WV Board of Optometry
1. Complaint is filed against
Date of Care
2. Person filing complaint (complainant)
3. Complainant's relationship with the person against whom complaint is being filed
4. Summary of complaint
Provide a summary of complaint
5. Other persons with knowledge of incident(s) giving rise to this complaint. (Include any practitioner or institution giving follow-up care.)
6. State in your own words how this incident(s) relates to the West Virginia Board of Optometry Jurisdiction.
7. Have you advised any other regulatory or legal authority of this complaint, i.e.: the Attorney General's office?
8. What action, if any, are you seeking from the Board?
I agree that all information is accurate to the best of my knowledge.