CLIENT INFORMATION FORM FOR 
TEXAS STATE BOARD OF MEDICAL EXAMINERS COMPLAINT

PERSONAL INFORMATION:

Name:________________________________________________________

Birthplace:_____________________________________________________

Date of Birth:___________________________________________________

Home Telephone Number:_________________________________________

Present Address:________________________________________________

Employer:______________________________________________________

Work Telephone Number:__________________________________________

Employer Address:_______________________________________________

Fax Number:____________________________________________________

How long have you worked for this employer?___________________________

MEDICAL BACKGROUND:

What year were you licenses to practice medicine?_______________________

How long have you been practicing medicine? __________________________

Are you licensed to practice medicine in any other jurisdictions?_____________

What areas does your practice cover? ________________________________

Please list all certifications _________________________________________

COMPLAINT INFORMATION:

Have you ever had a complaint filed against you?________________________

If yes, please describe when complaint was filed, what was alleged, and the
disposition of the complaint:________________________________________

______________________________________________________________

Besides the complaint described above, have any other complaints or malpractice lawsuits ever been filed against you?________________________

If yes, please describe each situation or complaint:_______________________

______________________________________________________________

PRESENT COMPLAINT MATTER:

What date did you receive this complaint?_____________________________

Is the complaint defined as an inquiry or complaint?______________________

Who is the Complainant?__________________________________________

What is your relationship to the Complainant?___________________________

What does the complaint allege?____________________________________

Have you responded to the complaint?________________________________

Where does the Complainant allege the violation occurred?________________


What are the allegations of the complaint?_____________________________

_____________________________________________________________

Please briefly respond to these allegations:____________________________
_____________________________________________________________

Have you attended a Settlement Hearing for this matter?_____________________________________________________________

If so, when and where:____________________________________________

Did you consent the proposed order?_________________________________

Please provide the names and addresses, including telephone numbers, of all witnesses concerning the complaint:

1. Witness Name:_______________________________________________

Address:______________________________________________________

Work Telephone:_______________ Home Telephone:___________________


2. Witness Name:_______________________________________________

Address:______________________________________________________

Work Telephone:_______________ Home Telephone:___________________


3. Witness Name:_______________________________________________

Address:______________________________________________________

Work Telephone:_______________ Home Telephone:___________________

4. Witness Name:_______________________________________________

Address:______________________________________________________

Work Telephone:________________ Home Telephone:__________________


5. Witness Name:_______________________________________________

Address:______________________________________________________

Work Telephone:_______________ Home Telephone:___________________


6. Witness Name:_______________________________________________

Address:______________________________________________________

Work Telephone:_______________ Home Telephone:__________________


Have you provided all the documents that pertain to this complaint?__________

Please explain how you heard about our firm?__________________________