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 l
awsuits 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?_______________________________