Patient Complaint Form

The New York State Dental Association is a private, voluntary, professional association for licensed dentists in New York State. Membership with the NYSDA is not a NYS dental license requirement.

Please complete the form below if you have a complaint regarding the dental work that was performed and/or how you were treated by a dentist.

IMPORTANT NOTE: The NYSDA does not take complaints regarding billing or how you were treated by the office staff. Please contact the dental practice owner directly to discuss your concerns.

Dentist's Information

Dentist's First Name

Dentist's Last Name

Dental Practice Name

Street Address

City

State

Zip Code

Your Contact Information

Your First Name

Your Last Name

Your Email Address

We will contact you with the appropriate next steps as soon as possible.

Patient Complaint Form

IMPORTANT NOTE: The NYSDA does not take complaints regarding billing or how you were treated by the office staff. Please contact the dental practice owner directly to discuss your concerns.

Dentist's Information

Your Contact Information

General Information

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