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Licensed 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 licensed 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 licensed 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? ______________________
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
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