Oklahoma Board of Medical Licensure and Supervision

Complaint

Please fill out the form to submit your complaint. Fields marked with * are required.

Patient info (if different from person filing complaint):

Patient first name:

Patient last name:

Patient date of birth (mm/dd/yyyy):

Your information:

Your first name:

Your last name:

Street:

Apartment or box #:

City:

State:

Zip code:

Phone number:

Email address:

Complaint against:

First name:

Last name:

Street:

Apartment or box #:

City:

State:

Zip code:

Phone number:

Profession:

Your complaint:

Nature of complaint: *

Incompetence

Sexual misconduct

Fraud

Medications

Malpractice

Substance abuse

Billing/Fees

Failure to transfer or provide records

Other

Your complaint: please provide, in your own words, a detailed statement of your complaint. Be as specific as possible about your concerns.

Upload additional pages as necessary. Also upload copies of any related documents.

Upload document:

Final information:

Do you have a copy of the relevant medical records? *

Yes No

I certify that the information above is true and correct to the best of my knowledge.

First and last name:

Date (mm/dd/yyyy):

This question is for testing whether you are a human visitor and to prevent automated spam submissions. Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.

What's 4 + 3:

Complaint

Patient information:

Your contact information:

Complaint against:

Your complaint:

Confirmation details:

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