Board of Chiropractic Examiners
4201 Patterson Avenue Baltimore, MD 21215-2299
PHONE: 410-764-4738, FAX: 410-358-2863WEBSITE: www.mdmassage.org
Certified Massage Therapists and Registered Massage Practitioners
Complaint Form
PLEASE PRINT OR TYPE IN BLACK INK:
The Board of Chiropractic Examiners (Board) investigates complaints filed against certified and registered massage therapists to determine if there is a violation of the Maryland Massage Therapy law. Whenever a complaint involves the practice of massage therapy by someone other than a certified or registered massage therapist, the information is certainly of interest to the Board and should be forwarded as soon as possible.
To assist in the processing of your complaint, include the correct names, addresses, both home and business telephone numbers of all persons named in the complaint. If certain information is not known, please indicate on the form.
All complaints are thoroughly reviewed and often referred for investigation. Should the Board bring charges against a massage therapist, advance notice must be given to the therapist to allow time to respond to the complaint and prepare a defense. Therefore, in most cases there will be a time lapse between filing of the complaint and scheduling a hearing.
You will be notified in writing as to the outcome of your complaint. Also, you may be called to testify as a witness if a Board hearing is scheduled.
If there is more
than one person filing this complaint, please use a separate form for each
person.
FULL NAME OF
MASSAGE THERAPIST: ________________________________
ADDRESS:
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TELEPHONE: _________________________________________________________
FULL NAME OF COMPLAINANT: ______________________________________
ADDRESS:
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HOME AND BUSINESS TELEPHONE:
(H)________________________________
(B)________________________________
YOUR DATE OF BIRTH: __________________________ AGE: _________________
Were you a patient of this Massage Therapist? ________Yes ________No
If so, from when to when ______________________ to _________________________.
Have you discussed your concerns with this massage therapist?
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What was the outcome ____________________________________________________
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Date (s) of occurrence (s) complained about ____________________________________
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Describe, in narrative form, with as much detail as possible, the exact nature
of your complaint against this massage therapist.
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State the names, addresses and telephone numbers of any witnesses to the
occurrence(s) complained of, including any persons who were present at the
time of the occurrence(s).
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For what condition were/are you being treated?
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Will you consent to the release to this Board or its designated investigating
body, reports or records relating to you and to this occurrence from any health
care provider or hospital, including the massage therapist complained of?
___________ Yes
__________ No.
If Yes, please
authorize by signature _________________________________________
If No,
why not? _________________________________________________________
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If the complaint is made by a person
other than the patient, acting in
an official or professional capacity, please furnish the following additional
information. Also, please be sure to read, sign and date of the last page of
this complaint form.
Your official title or designation
____________________________________________
Did you personally
investigate the matters set forth in this complaint?
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Do you have any reports or other written communications directed to you with
respect to the matters complained of?
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If so, please attach to this complaint copies of these communications.
Is
there any further information you wish to convey to the Board regarding this
complaint?
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Date of Complaint Signature of Complainant
I HEREBY CERTIFY AND AFFIRM UNDER THE PENALTIES OF PERJURY THAT THE MATTER AND
FACTS SET FORTH IN THE FOREGOING COMPLAINT ARE TRUE AND CORRECT, TO THE BEST OF
MY KNOWLEDGE, INFORMATION AND BELIEF.
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Date Signature
10/05DH