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

Complaint Form

Personal Information

First Name:                                                                                                                                                        

Middle Name:                                                                                                                                                   

Last Name:                                                                                                                                     

Gender: Male:_____          Female:_____

Home Address:                                                                                                                              

Home Phone:                                                                                                                                 

Cell Phone:                                                                                                                                     

Personal Email:                                                                                                                              


Name of Treating Practitioner:                                                                                                  

Office Address:                                                                                                                             

Office Phone:                                                          Office Fax:                                                   

Business Website:                                                   


[Please provide a detailed summary of the issues regarding the practice of indigenous medical care you received (or failed to receive) and submit additional supportive documents where appropriate]:


I understand that, as a member of the Turtle Healing Band, false statements made knowingly and willfully on complaint forms, including affidavits or other supporting documents submitted therewith, as well as the withholding of relevant information, may result in the dismissal of my complaint, prosecution for fees and costs associated with my complaint, and/or punitive damages for malicious defamation of character. Therefore, I declare under penalty of perjury that the information I have provided herein is true and correct.

Signature:                                                                Date:                                                          

                 MAIL                                        EMAIL                           FAX

First Nation Medical Board (702) 902-2862

2121 E. Flamingo Rd. #112

Las Vegas, Nevada 89119



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