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Patients

Patients: Please fill out the Patient Complaint Form only.

Dentists: Please scroll down and only fill out the Dentist's form. Please do not add patient identifying information to this message. Thank you!

PATIENT Complaint Form

Name:

Date of Birth

Email:

Phone:

Name of Dentist

Practice Address I was seen at:

Have you spoken with your dentist directly about your complaint?

Yes

No (Please do your best to speak directly with your dentist before filing a complaint)

If you have spoken to your dentist, what was the result?

I wasn't able to speak to my dentist directly because of front office staff.

We didn't agree/I didn't find the resolution I needed.

My complaint is a:

Billing dispute

Complaint about office staff who are NOT the dentist

Work that my dentist performed

Other

Please provide a short description of your complaint:

Thank you for contacting us.

Please note that Peer Review complaints are initially reviewed on Mondays, Tuesdays, and Thursdays. We will get back to you as soon as possible.

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DENTIST'S Referral

Name:

Email:

Phone:

I am:

SNDS Member

SNDS Non Member

I need:

more information about this program!

to refer a patient.

Message:

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We will get back to you as soon as possible.

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Patient Information

Since 1940 | Professional Staff | Non-Profit Organization

Since 1940
Professional Staff
Non-Profit Organization

Hours:

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