First name * Last name * Email * Phone number * Address * City * Province * Postal code * Dental Hygienist name * Dental Hygienist Registration Number Find a Dental Hygienist's Registration Number here Clinic name * Clinic phone number * Clinic address * Clinic city * Complaint * Submit all relevant details of your complaint here. Supporting documentation Upload any relevant and supporting documentation here. Choose File No file chosen The maximum total size of all files in a single form submission is 1 GB. Leave Blank
