Georgia Professional Licensure Complaint Form

Dentistry

Please use the following form to submit a complaint to the Georgia Board of Dentistry.

The Board investigates complaints of alleged violations of the Georgia Dental Practice Act and the Board’s rules. Please be advised that the Board does not have the authority to settle fee disputes, nor does it settle personality conflicts. You may use the following form to submit a complaint to the Georgia Board of Dentistry if your complaint pertains to the practice of dentistry or dental hygiene.

NOTE: All fields marked with asterisks (*) are mandatory.

Your Name (required)

Street Address (required)

City (required)

State (required)

Zip Code (required)

Your Telephone (required)

Enter area code and phone number as 123-456-7890

FAX

Enter area code and phone number as 123-456-7890

Your E-mail (required)

Area of Complaint

Quality of Care/Service

Unlicensed Practice

Unprofessional Conduct

Other

Patient(s) Name

Patient(s) Name
	Patient(s) Name Title Title Enter other… First (required) Middle Last (required) Suffix	Item weight

more items

Name of Licensee (required)

NOTE: The Georgia Board of Dentistry ('Board') does not have authority over dental groups, practices, clinics or offices. Therefore you must provide the full name -- first and last -- of the individual dentist and/or hygienist who is the subject of the complaint.

Please provide the first and last name of the dentist/hygienist that is the subject of the complaint.

Professional Entity

License Number

Licensee/Facility Address

Complete Address (include street, city, state and zip)

Licensee/Facility Phone

Enter area code and phone number as 123-456-7890

Have you brought any legal action against this licensee/professional entity?

If you have pursued resolution through mediation or peer review, please provide the name of the organization that you contacted and the dates for such actions.

Have you seen another dentist about this issue?

If yes please provide the first and last name of subsequent treating dentist or physician

Detailed Complaint Information

Please provide a detailed explanation of your complaint, including full names, addresses, dates, etc. regarding all parties involved. Please keep a copy of this complaint information for your records. Once it is possessed by the Board, it is confidential under state law and cannot be provided back to you.

Georgia Professional Licensure Complaint Form

Dentistry

Please use the following form to submit a complaint to the Georgia Board of Dentistry.

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