Submit Concerns About a Chiropodist or Podiatrist

A) PERSON SUBMITTING THE CONCERN:

* required information

Last Name *

First Name *

Home Address *

City *

Province *

Postal Code *

Country

Home Phone *

Mobile Phone

Email *

B) CHIROPODIST OR PODIATRIST WHO YOU HAVE CONCERNS ABOUT:

Last Name *

First Name *

COCOO Registration # (if possible)

C) 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:

Please provide a detailed outline of your concern(s). *

Are there other people who witnessed this? *
YesNo

D) ACKNOWLEDGEMENT

By clicking "Submit" I understand that I am filing a formal complaint against the Chiropodist/Podiatrist mentioned in section B.