Submit Concerns About a Chiropodist or Podiatrist

PERSON SUBMITTING THE CONCERN:

* required information

Last Name *

First Name *

Home Address *

City *

Province *

Postal Code *

Country

Home Phone *

Mobile Phone

Email *

CHIROPODIST OR PODIATRIST WHO YOU HAVE CONCERNS ABOUT:

Last Name *

First Name *

COCOO Registration # (if possible)

DETAILS OF YOUR CONCERNS:

Where did you see the Chiropodist or Podiatrist? *
HospitalClinicPatient’s HomeOther
Please provide the name and address of the facility/institution:

When did you see the Chiropodist or Podiatrist perform/behave in this way? *
(please provide ALL dates, if possible)

Please provide an outline of your concern(s). *

Are there other people who witnessed this? *
YesNo

What would you like to see happen as a result of submitting this concern? *