Cosmetology complaint form

Your name

Your number

Your email

If you don't provide name, number or email, then you will not be able to ask about the status of the investigation or receive any results of the investigation.
Facility information
Name
Address (street/city/ZIP code)
Complaint information
Have you reported your concerns to the local health department?YesNo
Have you spoken with anyone at the facility regarding your concerns?YesNo
If yes, with whom did you speak and has there been any change?
Incident details
Provide as much information about your concerns including date(s), time, names of individuals involved and their titles, names of witnesses and their contact information, where the incident(s) occurred, etc.