medical licensing for providers of medial alternatives and public memberships for patients seeking for health optimization and wellness

Complaint Form

Personal Information

Date:                                             

First Name:                                                                                                                                                        

Middle Name:                                                                                                                                                    

Last Name:                                                                                                                                                         

Gender: Male:_____          Female:_____

Home Address:                                                                                                                                                 

Home Phone:                                                                                                                                                    

Cell Phone:                                                                                                                                                        

Personal Email:                                                                                                                                                 

Practitioner

Name of Treating Practitioner:                                                                                                                      

Office Address:                                                                                                                                                

Office Phone:                                                                       Office Fax:                                                          

Business Website:                                                   

Summary

[Please provide a detailed summary of the issues regarding the practice of indigenous medical care you received (or failed to receive)]

                                                                                                                                                                             

                                                                                                                                                                             

                                                                                                                                                                             

                                                                                                                                                                             

                                                                                                                                                                             

                                                                                                                                                                             

                                                                                                                                                                             

                                                                                                                                                                             

                                                                                                                                                                             

                                                                                                                                                                             

                        MAIL                                                   EMAIL                            FAX

First Nation Medical Board info@FirstNationMedicalBoard.com (702) 902-2862

2121 E. Flamingo Rd. #112

Las Vegas, Nevada 89119

Phone:
702-562-1454

Email:
Info@firstnationmedicalboard.com

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