Complaint Process

New Jersey Office of the Attorney General

Division of Consumer Affairs

State Board of Veterinary Medical Examiners

124 Halsey Street, 6th Floor, P.O. Box 45020

Newark, New Jersey 07101

(973) 504-6500

Complaint Process

As a unit of the Division of Consumer Affairs, the State Board of Veterinary Medical Examiners (Board), takes its

responsibility seriously. A copy of the complaint will be forwarded to the licensee with a cover letter from the Board requir-

ing a detailed written response to the allegations in the complaint. Once that response has been received, it will be reviewed

and disposition may be recommended. If the Board needs additional information, the licensee may be required to appear to

answer questions concerning the matter.

Please be advised that any information you supply on the complaint form may be subject to public disclosure. If an

investigation into the matter is conducted, the information is subject to public disclosure only after the completion of the

investigation. You are also advised that the completed complaint form is a “government record,” which the Board may be

obligated to provide to anyone making a request pursuant to the Open Public Records Act (OPRA).

The disposition of the matter may take several months. Please understand that the Board can only take formal action if it

finds sufficient basis that the licensee violated State laws or regulations. If the Board determines that formal action is re-

quired, the matter is referred to the office of the Attorney General. In that case, formal charges may be filed against the

licensee and the licensee will be given an opportunity to defend himself or herself. This process can take a considerable

period of time.

If the complaint involves a dispute over fees, please be advised that the Board has limited jurisdiction over fees charged

by professionals. If the Board determines that there is insufficient basis to pursue disciplinary action, but determines that the

matter involves a fee dispute, your complaint may be referred to the Alternative Dispute Resolution (ADR) Unit of the

Division of Consumer Affairs. The ADR is a free mediation service that can be helpful in resolving such matters.

Until a final determination has been made, the Board is not permitted to disclose information regarding the matter. You

will be notified in writing when a final determination has been made.

(include area code)

Street address City State ZIP code

New Jersey Office of the Attorney General

Division of Consumer Affairs

State Board of Veterinary Medical Examiners

124 Halsey Street, 6th Floor, P.O. Box 45020

Newark, New Jersey 07101

(973) 504-6500

Complaint Form

Please print clearly.

Please be advised that any information you supply on this complaint form may be subject to public disclosure. If an

investigation into the matter is conducted, the information is subject to public disclosure only after the completion of the

investigation. You are also advised that the completed complaint form is a “government record,” which the Board may be

obligated to provide to anyone making a request pursuant to the Open Public Records Act (OPRA).

Consumer Information Complaint Reported Against

NAME:_________________________________________ NAME:_________________________________________

ADDRESS: ______________________________________ BUSINESS NAME: _________________________________

CITY:__________________________________________ ADDRESS: ______________________________________

STATE:___________________ZIP CODE:______________ CITY:__________________________________________

HOME TELEPHONE NUMBER: _________________________ STATE:_______________________ZIP CODE:__________

WORK TELEPHONE NUMBER: ________________________ TELEPHONE NUMBER: ______________________________

FAX NUMBER: ___________________________________ TITLE: _________________________________________

E-MAIL ADDRESS: ________________________________ LICENSE NUMBER (IF KNOWN): _______________________

DATE: _________________________________________ DATES OF TREATMENT/SERVICE:

FROM: ___________________ TO: __________________

1. Animal’s name: _____________________________________________________________ Sex: ______________

Animal species (dog, cat, bird, horse, etc.):________________________________________

Breed: ______________________________________________ Animal’s age at the time of the incident:_________

2. Please provide the following information about any other veterinarian who saw the animal after the incident.

Name: ________________________________________________________________________________________

Title: _________________________________________ License number: _________________________________

Address: ______________________________________________________________________________________

Telephone number:________________________________

(include area code)

(include area code) (include area code)

Name: ________________________________________________________________________________________

Title: _________________________________________ License number: _________________________________

Address: ______________________________________________________________________________________

Telephone number:________________________________

3. What is the nature of the complaint? (Please check all that apply and provide any additional comments on a separate

sheet of paper.)

Negligence Professional misconduct

Misdiagnosis Unsanitary office conditions

Failure to respond to an emergency False or misleading advertising

Refusal to release patient records Failure to obtain consent for treatment

due to an unpaid balance

Other ____________________________________

Please be advised that the Board is permitted by law to take action in cases of professional misconduct, gross negligence

or repeated acts of negligence. Therefore, you should be aware that (1) complaints based solely upon conduct such as

poor communication skills or poor “bedside manner” may not be actionable under the law; and (2) the Board does not

handle fee disputes.

4. Please describe the facts of your complaint in the order in which they happened. Please print clearly. You may use

additional sheets of paper if they are needed.

_______________________________________________________________________________

All complaints must be accompanied by readable copies (NO ORIGINALS) of any complaint-related documents, patient

records, test results, correspondence or any other documents you feel are related to your complaint.

In order to resolve your complaint, we may send a copy of your complaint to the veterinarian(s) about whom you are

complaining.

I hereby authorize the release of all medical records, X-rays and other documents related to the diagnosis, prognosis and

treatment of my animal by the treating veterinarian(s) to the State Board of Veterinary Medical Examiners.

5. I certify that the statements made by me in this complaint are true and any documents attached are true copies. I am

aware that if any statements made by me are willfully false, I am subject to punishment.

_______________________________________________ ____________________

Signature* Date

Return to:

Division of Consumer Affairs

State Board of Veterinary Medical Examiners

P.O. Box 45020

Newark, NJ 07101

* This certification must be signed by the person who has completed this form.

(include area code)

Street address City State ZIP code

2/8/05