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Print E-CertificateTexas State Board of Dental Examiners 2025

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The document is a complaint form from the Texas State Board of Dental Examiners, providing instructions for filing complaints against dental practitioners. It outlines the types of complaints that can be submitted, the complaint process, and the actions the board may take. The form requires personal information from both the complainant and the practitioner being complained about, as well as details regarding the nature of the complaint. It also includes a records release authorization for relevant health information.

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Click ‘Get Form’ to open it in the editor.
Begin by filling out the 'Person Filing Complaint' section. Provide your name, address, phone number, and email. Ensure all information is legible to avoid processing delays.
Next, identify the patient involved by completing their details in the 'Patient' section. If the patient is yourself, you can check the box indicating 'Same as Person Filing Complaint'.
In the 'Complaint Against' section, provide details about the licensee you are filing against. Include their name, address, and license number if known.
Clearly describe the nature of your complaint in the designated area. Attach any supporting documentation that may help substantiate your claims.
Finally, review all entered information for accuracy before signing and dating the form at the bottom.

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Versions	Form popularity	Fillable & printable
2022	4.1 Satisfied (45 Votes)
2015	4.1 Satisfied (20 Votes)

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