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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):
Your information:
Complaint against:
Your complaint:

Nature of complaint: *

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

Final information:

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

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


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.

Patient information:

Patient first name:

Patient last name:

Patient date of birth:

Your contact information:

First name:

Last name:

Street:

Apartment or box:

City:

State:

Zip code:

Phone #:

Email:

Complaint against:

First name:

Last name:

Street:

Apartment or box:

City:

State:

Zip code:

Phone #:

Profession:

Your complaint:

Nature of complaint:

Complaint:

Confirmation details:

Medical records available:

Electronic signature:

Date:

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