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State of Nevada Board of Veterinary Medical Examiners Kietzke by robyniscrazy

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									                        State of Nevada Board of Veterinary Medical Examiners
                        4600 Kietzke Lane, Bldg. O, #265, Reno, NV 89502
                        (775) 688-1788 phone / (775) 688-1808 fax




                               Consumer Complaint
  YOUR INFORMATION                                                       VETERINARIAN(S) NAMED IN COMPLAINT
  Name: ___________________________________________________              Name: _____________________________________________________
  Address: _________________________________________________             Address: ___________________________________________________
  City: __________________________State: ______ Zip: ___________         City: ___________________________ State: _____ Zip: ___________
  Daytime Phone#_______________ Evening Phone #______________            Telephone: _________________________________________________
  Best number and time to call__________________________________
  ANIMAL’S INFORMATION

  Animal’s Name: __________________________________________ Animals Breed : ______________________________________
  COMPLAINT
  State Your Complaint (Please be specific as to times, dates and places. Attach additional pages if necessary)
  ________________________________________________________________________________________________________________________
  ____________________________________________________________________________________________________________
  ____________________________________________________________________________________________________________
  ____________________________________________________________________________________________________________
  ____________________________________________________________________________________________________________
  ____________________________________________________________________________________________________________
  ____________________________________________________________________________________________________________
  ____________________________________________________________________________________________________________
  ____________________________________________________________________________________________________________
  ________________________________________________________________________________________________________________________




Have you discussed this complaint with the veterinarian?                          Yes      No   .........

How did you file the complaint?                   Letter      Telephone         Other
Consulting Veterinarian(s) (if any):
___________________________________________                    _______________________________________________________
Name                                                           Address
Any Witness(es) present:
__________________________________               ___________________________________________                      ____________________
Name                                             Address Telephone


Will you testify at a hearing regarding this complaint?                       Yes       No



____________________________________________________________________________________
 Signature                                                                              Date



                                                  Consumer Complaint Page 1 of 1

								
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