Complaint Reporting Form

  • Complaint Reporting Form

  • The College of Acupuncturists of Alberta investigates complaints about registered acupuncturists in Alberta. The information collected on this form, including your personal information, is collected under the authority of the Health Professions Act and will be used to process your complaint.

  • Your information

  • Format: (000) 000-0000.

  • Do you agree to receive all correspondence and documents by email?*
  • What's your role in this complaint?*
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  • Incident details

  • Date of incident*
     - -
  • Have you discussed this matter with the acupuncturist?*
  • This complaint involves:*
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  • Were there any witnesses?*
  • Have you submitted a complaint to any other organization (e.g., police, Alberta Health Services)?*

  • Resolution

  • The College has the authority to investigate concerns and discipline its members, but cannot provide financial compensation for damages. That is a matter to be addressed in civil court.

  • What do you hope will happen as a result of the complaint?*

  • Sign

  • I understand and acknowledge that:

    1. The Registered Member, as named in this complaint, will be notified of my complaint and will be provided a copy of the complaint.
    2. The College of Acupuncturists of Alberta may obtain the patient's/my personal health information, such as diagnostic, treatment, and patient care information, when relevant and if this matter is investigated.
    3. Any information collected during an investigation will be used for the College of Acupuncturists of Alberta’s complaint process.
    4. Your information may only be disclosed in accordance with the Health Professions Act and the Personal Information Protection Act or with your consent.

  • Date and sign the form. Your typed or electronic signature is considered as legally valid as your handwritten signature on this form.

  • Date signed*
     - -
  • Should be Empty: