Consumer Complaint Form – Alabama State Board of Podiatry

Your Name:*

Your Email:*

Your Address:*

City:*

State:*

ZIP:*

Phone:*

Work Phone

Name of Podiatrist:*

Podiatrist Address:

Podiatrist City:

Podiatrist State:

Podiatrist ZIP:

Podiatrist Phone:

Date of Rendered Services or Visit:*

How Did You Learn About the Complainant?:*

Please Explain the Entire Circumstances Surrounding Your Complaint Including Your Attempts to Solve the Problem:*

Date:*

CONFIRMATIONThe Above is True and Accurate to the Best of My Knowledge.