Do you have a case pending with the Kansas Dental Board concerning this case?

• Yes
• No

Date

mm/dd/yyyy

Salutation Mr. Ms. Mrs. Dr.

Patient Name

Email

Patient Phone

May we contact you via email regarding this case?

• Yes
• No

Patient Address

(Street, City, State , ZIP)

Dentist Name

Dentist Email

email@me.com

Dentist Address

(Street, City, State , ZIP)

Have you contacted the dentist office about your concerns? Yes No

When was your last appointment with the dentist?*

(Day, Month, Year)

Please describe the problem(s) specific to the dental treatment received. While a refund of any charges you may have paid is one of the options that may be recommended by the mediator, a request for a refund should not be made in writing or on this form.*

I certify that I am at least 18 years old and am the patient or the parent/legal guardian of the patient. In order that a complete review be performed, I understand that I must authorize the release of any dental records or information by anyone who has examined the patient, previously, to the Kansas Dental Association Council on Peer Review.*

(Sign Your Name First, Last)

Submit