Form Test If you submit a complaint via email or through the online Complaint Form and do not receive confirmation of receipt within 3 business days, please contact the College to confirm it was received. Step 1 : PERSON REGISTERING COMPLAINT *required information Preferred Title* Dr.Mr.Mrs.Ms.MissMxPrefer not to say Last Name* First Name* Street Address (Line 1) Street Address (Line 2) City Province Postal Code Country Home Phone* Mobile Phone Email* STEP 2 : DENTAL HYGIENIST WHO YOU HAVE CONCERNS ABOUT Last Name First Name CDHO Registration # (if available) Where did you see the Dental Hygienist? Name of Dental / Dental Hygiene Practice Address of facility / institution Street Address (Line 1) Street Address (Line 2) City Province Postal Code STEP 3 : DETAILS OF YOUR CONCERNS Description of Events* Please provide a detailed outline of your concern(s) Witnesses Please provide names and addresses of other people who witnessed this Upload Documents Allowed file types (word, pdf, mp3, mp4) By clicking SUBMIT below I understand that I am filing a formal complaint against the Dental Hygienist mentioned above
