Compliment - Therapist or Establishment : Louisiana Board of Massage Therapy

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THERAPIST / ESTABLISHMENT INFORMATION
*Therapist / Establishment Name:
*Phone Number of Individual or Business:
*Address of Individual or Business:	Address City State Zip
*Date of Service/ Date Incident(s) Occurred:
*Location where Incident(s) Occurred:
CUSTOMER / COMPLAINANT CONTACT INFORMATION
*Name:	First Last
*Phone Number:
*Mailing Address:	Address City State Zip
*E-Mail:
*Contact Preference:	Phone Mail E-Mail
CUSTOMER / COMPLAINANT FEEDBACK
*Comments / Detailed Description of the Incidents(s) that Resulted in this Complaint:
To complete this form, you will be required to enter a digital signature which will be binding as your actual signature. Your electronic signature below indicates your agreement to the following statement: By checking the "I Agree" box below, I certify that all statements and representations contained on this form are true and correct, to the best of my knowledge, and that this information can be used for the purpose of the Louisiana Board of Massage Therapy to review and/or investigate and resolve this matter in accordance with the Board's rules and regulations.
Electronic Signature: I Agree. Date Signed: