Complaint Reporting Form

Before you lodge a formal complaint, please review the Complaint Process page (LINK).

Although the College will receive your concern more quickly if you complete the form below, a .pdf of the form below may be found here: Complaint Form and sent to the College. This may be received by mail, fax, or email (complaints@abdenturists.ca).

Your Information (the Complainant)

Full Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

email address

Phone number *

Communication Preference

Please check one option.

email - I choose email as my main communication preference. Send complaint correspondence to the email address provided above. I consent to receive information via email from the College and its representatives for the purposes of this complaint.
Canada Post - I choose mail as my main communication preference. Send complaint correspondence to the mailing address provided above.

Representative Information

If you are a representative of the complainant, please provide your details below. Please send any authorizing documentation to info@abdenturists.ca.

Full name

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Relationship to Complainant

e.g., guardian, power of attorney

Phone number

email address

Denturist Information

Denturist's Name *

Clinic Name *

Clinic Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Clinic Phone Number

Your Concern

Please provide a clear description of the concern you have about the denturist who you have identified. Please include as much detail as possible. In your description, include what the denturist did, or failed to do, to cause you to contact the College: (a) what happened; (b) where it happened; and (c) when it happened (in chronological order)

Concern *

Witness Information

Please identify any individual(s), if applicable, who ma have information about the incident (e.g., family, clinic staff).

Witness #1 Name

First

Last

Phone number

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Email address

Information they may have:

Witness #2 Name

First

Last

Phone number

email address

Address

Address Line 1

Address Line 2

City

State

Zip Code

Information they might have:

Witness #3 Name

First

Last

Phone number

email address

Address

Address Line 1

Address Line 2

City

State

Zip Code

Information they might have:

Additional Information Requested

What do you hope will happen as a result of your complaint? *

Note: the College cannot provide nor direct the denturist to provide financial compensation. If you are looking for financial compensation, you may wish to obtain legal advice.

Relevant documents or evidence to support your concern

If you have any supporting documentation that will assist us in assessing your concern, please submit copies via email to info@abdenturists.ca and itemize the documentation and provide a brief description.

Understanding and Signature

I understand and acknowledge that: (1) If accepted by the College, the denturists, as named above, will be notified of my complaint, and will be provided a copy of this submitted form; (2) The College of Alberta Denturists may collect, use, and/or disclose the patient's/my personal health information, such as diagnostic, treatment, and patient care information when relevant, and if this matter is investigated any information collected during an investigation will be used for the College of Alberta Denturists professional conduct processes; and (3) Your information may only be disclosed in accordance with the HPA and the Personal Information Protection Act or with your consent.

Signature *

Clear Signature

Date / Time

Date

Time

Your Privacy is Important to Us

We collect, use, and/or disclose your personal information with your consent, unless otherwise authorized by legislation, to do our work as the regulatory body for the denturist profession. Our work is to protect the public and to guide and regulate Alberta denturists.

93463