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TENNESSEE DENTAL ASSOCIATION PATIENT REQUEST FOR MEDIATION Upon receipt of this completed form, a mediator will be assigned and will contact you to discuss your request and attempt to resolve the
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How to fill out "state your complaint" forms:

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Start by clearly identifying the name and contact information of the person or organization you are filing the complaint against. This includes their full name, address, phone number, and any other relevant information.
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Provide a detailed description of the issue or incident that you are complaining about. Be specific and provide all relevant facts and details to support your complaint. This could include dates, times, locations, and any other pertinent information.
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Clearly articulate what resolution or action you are seeking from the person or organization. Whether it is a refund, compensation, apology, or any other specific outcome, make sure to state it clearly and concisely.
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If applicable, attach any supporting documents or evidence that can strengthen your complaint. This could be photographs, emails, receipts, or any other relevant documentation that supports your claims.
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Who needs to state their complaint?

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Consumers who have encountered issues with a product, service, or company can state their complaint to seek resolution or compensation.
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