Complaint Form

Complaint and Feedback Form

Type of Business(Required)

Massage Therapist

Massage Therapy Spa/Clinic

Cosmetology Practitioner

Cosmetology Establishment

Body Art/Permanent Cosmetic Artist

Body Art/Permanent Cosmetic Establishment

Complaint Reported By(Required)

First Last

Complaint Reported By Email(Required)

Complaint Reported By Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Complaint Reported By Phone Number(Required)

Date of Occurrence(Required)

Time of Occurrence(Required)

Name of Therapist, Spa/Clinic, Practitioner, or Establishment(Required)

Address of Establishment(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number of Establishment(Required)

Briefly describe the violation: