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WV Board of Optometry
Complaint Form
1. Complaint is filed against
First Name
Last Name
Email Address
Address
City
State
Zip Code
Date of Care
2. Person filing complaint (complainant)
First Name
Last Name
Email Address
Address
City
State
Zip
3. Complainant's relationship with the person against whom complaint is being filed
Relationship
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.)
Name
Phone
Address
Name
Phone
Address
6. State in your own words how this incident(s) relates to the West Virginia Board of Optometry Jurisdiction.
Provide details
7. Have you advised any other regulatory or legal authority of this complaint, i.e.: the Attorney General's office?
Provide Details
8. What action, if any, are you seeking from the Board?
Provide Details
I agree that all information is accurate to the best of my knowledge.
Current Date
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