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Oregon Board of Massage Therapists

Submit a Complaint
COMPLAINANT Information
(consumer, client or authorized representative)
Name
 Home Number
Street Address
 Work Number
City/Town
 County
 State
 Zip Code
Cell Number
e-mail address
  
RESPONDENT Information
(LMT, unlicensed practitioner or facility)
Name
 Home Number
Street Address
 Work Number
City/Town
 County
 State
 Zip Code
Cell Number
e-mail address
  

What violation(s) do you believe have occurred? (Check all that apply):
Ad without license Number Ethics / Boundary Issue
Failure to Provide Services Paid For Injury to Client
Insurance / Billing Fraud Out of Scope
Professional Misconduct Sanitation Issue
Sexual Misconduct Substance abuse / Impairment
Unlicensed Advertising Unlicensed Practice
Practice While Lapsed, Suspended, Revoked, or Expired
Other (please explain)

How did you learn of this provider?


Have you addressed the issue with the practitioner?  If yes, when and what happened?


Did you file a police report?    Yes    No
When:  
Where:  
Case Number:  
Have you obtained an attorney?    Yes    No
Attorney Information:
Name:  
Address:  
 
Phone:         Fax:  

Would you voluntarily testify if this matter goes to a formal hearing?    Yes    No
Comments:
What would be your desired outcome of this complaint?

Describe the incident / complain and provide full details that include facts, dates, locations, witnesses, etc.  Please send copies of medical records, correspondence, contracts, checks, credit card receipts, advertisements, business cards, or other supporting documentation.
(Type as much as you want as the box will expand as necessary)


By checking this box and filling in the date box below, I certify that the statements made and documentation provided by me in this complaint are true and correct to the best of my knowledge, information, and belief and that any documentation attached are true copies.
Date:
WITNESS Information
Name
 Home Number
Street Address
 Work Number
City/Town
 County
 State
 Zip Code
Cell Number
e-mail address
 Relationship to complainant

WITNESS Information
Name
 Home Number
Street Address
 Work Number
City/Town
 County
 State
 Zip Code
Cell Number
e-mail address
 Relationship to complainant

WITNESS Information
Name
 Home Number
Street Address
 Work Number
City/Town
 County
 State
 Zip Code
Cell Number
e-mail address
 Relationship to complainant

WITNESS Information
Name
 Home Number
Street Address
 Work Number
City/Town
 County
 State
 Zip Code
Cell Number
e-mail address
 Relationship to complainant



QUESTIONNAIRE TO ACCOMPANY COMPLAINTS OF UNLICENSED PRACTICE

How do you know the subject of the complaint?


How did you become aware of the alleged unlicensed practice?


When did you become aware of the alleged unlicensed practice?


Location or occurrence of alleged unlicensed practice?


Time(s) and date(s) of treatment or incident?


If payment was made, how was the subject paid?

Was there advertising or do you have copies of advertisements?    Yes    No (If yes, please send copies - advertising would be flyers, business cards, internet ads, newspaper ads, etc)

Physical Description of subject:

Gender:
Skin Color: Height:
Hair Color: Weight:
Eye Color:

Description of vehicle:

Year: Make: Model: Color: Plate Number:

Have you notified local law enforcement or any other agency about the offense?
   Yes    No If yes, please provide Agency information:
Name:  
Address:  
 
Telephone Number:  
Case Number:  
Investigator assigned to your case:  


 
Page updated: September 18, 2008

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