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.