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Submission: On July 08 via automatic, source certstream-suspicious — Scanned from DE
Submission: On July 08 via automatic, source certstream-suspicious — Scanned from DE
Form analysis 1 forms found in the DOM
POST /
<form class="node-form node-complaint-form" enctype="multipart/form-data" action="/" method="post" id="complaint-node-form" accept-charset="UTF-8">
<div>
<div class="form-item-title form-wrapper form-group" id="edit-title-field">
<div id="title-field-add-more-wrapper"></div>
</div><input type="hidden" name="changed" value="">
<input type="hidden" name="form_build_id" value="form-GhWGp7qwf2Cn_aee-EBPCjvLiwmvd49Kz-KTJvtzkSY">
<input type="hidden" name="form_id" value="complaint_node_form">
<div class="field-type-markup field-name-field-instructions field-widget-markup form-wrapper form-group" id="edit-field-instructions">
<div id="field-instructions-add-more-wrapper">
<div class="row">
<div class="col-sm-12">
<p>This form is designed to assist you in filing a complaint regarding a podiatrist (DPM). You will assist the North Carolina Board of Podiatry Examiners in investigating your complaint by providing as much of the requested information as
possible. You may upload or attach any additional pages or other information relating to your complaint.</p>
</div>
</div>
</div>
</div>
<div class="field-type-markup field-name-field-your-info field-widget-markup form-wrapper form-group" id="edit-field-your-info">
<div id="field-your-info-add-more-wrapper">
<div class="row">
<div class="col-sm-12">
<h3>Your Information:</h3>
<hr>
</div>
</div>
</div>
</div>
<div class="field-type-text field-name-field-first-name-complaintent field-widget-text-textfield form-wrapper form-group" id="edit-field-first-name-complaintent">
<div id="field-first-name-complaintent-add-more-wrapper">
<div class="form-item form-item-field-first-name-complaintent-und-0-value form-type-textfield form-group"> <label class="control-label" for="edit-field-first-name-complaintent-und-0-value">Complainant First Name <span class="form-required"
title="This field is required.">*</span></label>
<input class="text-full form-control form-text required" type="text" id="edit-field-first-name-complaintent-und-0-value" name="field_first_name_complaintent[und][0][value]" value="" size="60" maxlength="255">
</div>
</div>
</div>
<div class="field-type-text field-name-field-last-name-complaintent field-widget-text-textfield form-wrapper form-group" id="edit-field-last-name-complaintent">
<div id="field-last-name-complaintent-add-more-wrapper">
<div class="form-item form-item-field-last-name-complaintent-und-0-value form-type-textfield form-group"> <label class="control-label" for="edit-field-last-name-complaintent-und-0-value">Complainant Last Name <span class="form-required"
title="This field is required.">*</span></label>
<input class="text-full form-control form-text required" type="text" id="edit-field-last-name-complaintent-und-0-value" name="field_last_name_complaintent[und][0][value]" value="" size="60" maxlength="255">
</div>
</div>
</div>
<div class="field-type-text field-name-field-first-name field-widget-text-textfield form-wrapper form-group" id="edit-field-first-name">
<div id="field-first-name-add-more-wrapper">
<div class="form-item form-item-field-first-name-und-0-value form-type-textfield form-group"> <label class="control-label" for="edit-field-first-name-und-0-value">Complainant Full Address (Street, City, State, Zip) <span class="form-required"
title="This field is required.">*</span></label>
<input class="text-full form-control form-text required" title="" data-toggle="tooltip" type="text" id="edit-field-first-name-und-0-value" name="field_first_name[und][0][value]" value="" size="60" maxlength="50"
data-original-title="Street Address, City, State, Zip">
</div>
</div>
</div>
<div class="field-type-phone field-name-field-your-telephone-home- field-widget-phone-textfield form-wrapper form-group" id="edit-field-your-telephone-home-">
<div id="field-your-telephone-home-add-more-wrapper">
<div class="form-item form-item-field-your-telephone-home--und-0-value form-type-textfield form-group"> <label class="control-label" for="edit-field-your-telephone-home-und-0-value">Complainant Telephone (Home/Mobile) <span
class="form-required" title="This field is required.">*</span></label>
<input class="form-control form-text required" type="text" id="edit-field-your-telephone-home-und-0-value" name="field_your_telephone_home_[und][0][value]" value="" size="17">
</div>
</div>
</div>
<div class="field-type-phone field-name-field-telephone-work- field-widget-phone-textfield form-wrapper form-group" id="edit-field-telephone-work-">
<div id="field-telephone-work-add-more-wrapper">
<div class="form-item form-item-field-telephone-work--und-0-value form-type-textfield form-group"> <label class="control-label" for="edit-field-telephone-work-und-0-value">Complainant Telephone (Work)</label>
<input class="form-control form-text" type="text" id="edit-field-telephone-work-und-0-value" name="field_telephone_work_[und][0][value]" value="" size="17">
</div>
</div>
</div>
<div class="field-type-email field-name-field-email field-widget-email-textfield form-wrapper form-group" id="edit-field-email">
<div id="field-email-add-more-wrapper">
<div class="text-full-wrapper">
<div class="form-item form-item-field-email-und-0-email form-type-textfield form-group"> <label class="control-label" for="edit-field-email-und-0-email">Email <span class="form-required" title="This field is required.">*</span></label>
<input class="form-control form-text required" type="text" id="edit-field-email-und-0-email" name="field_email[und][0][email]" value="" size="60" maxlength="128">
</div>
</div>
</div>
</div>
<div class="field-type-list-text field-name-field-please-check-the-appropria field-widget-options-buttons form-wrapper form-group" id="edit-field-please-check-the-appropria">
<div class="form-item form-item-field-please-check-the-appropria-und form-type-radios form-group"> <label class="control-label" for="edit-field-please-check-the-appropria-und">PLEASE CHECK THE APPROPRIATE BOX <span class="form-required"
title="This field is required.">*</span></label>
<div id="edit-field-please-check-the-appropria-und" class="form-radios">
<div class="form-item form-item-field-please-check-the-appropria-und form-type-radio radio"> <label class="control-label" for="edit-field-please-check-the-appropria-und-1"><input type="radio" id="edit-field-please-check-the-appropria-und-1"
name="field_please_check_the_appropria[und]" value="1" class="form-radio">The Board of Podiatry Examiners has my permission to share this complaint with the podiatrist named below.</label>
</div>
<div class="form-item form-item-field-please-check-the-appropria-und form-type-radio radio"> <label class="control-label" for="edit-field-please-check-the-appropria-und-2"><input type="radio" id="edit-field-please-check-the-appropria-und-2"
name="field_please_check_the_appropria[und]" value="2" class="form-radio">The Board of Podiatry Examiners does not have my permission to share this complaint with the podiatrist named below.</label>
</div>
</div>
</div>
</div>
<div class="field-type-markup field-name-field-please-note- field-widget-markup form-wrapper form-group" id="edit-field-please-note-">
<div id="field-please-note-add-more-wrapper">
<div class="row">
<div class="col-sm-12">
<p><em>Please note: If this complaint cannot be shared with the podiatrist, the Board will accept it as information only and no further action may be taken.</em></p>
</div>
</div>
</div>
</div>
<div class="field-type-markup field-name-field-podiatrist field-widget-markup form-wrapper form-group" id="edit-field-podiatrist">
<div id="field-podiatrist-add-more-wrapper">
<div class="row'>
<div class=" col-sm-12="">
<h3>CONTACT INFORMATION FOR THE PODIATRIST<small> (about whom the complaint is made):</small></h3>
<hr>
</div>
</div>
</div>
<div class="field-type-text field-name-field-podiatrist-first-name field-widget-text-textfield form-wrapper form-group" id="edit-field-podiatrist-first-name">
<div id="field-podiatrist-first-name-add-more-wrapper">
<div class="form-item form-item-field-podiatrist-first-name-und-0-value form-type-textfield form-group"> <label class="control-label" for="edit-field-podiatrist-first-name-und-0-value">Podiatrist First Name <span class="form-required"
title="This field is required.">*</span></label>
<input class="text-full form-control form-text required" type="text" id="edit-field-podiatrist-first-name-und-0-value" name="field_podiatrist_first_name[und][0][value]" value="" size="60" maxlength="255">
</div>
</div>
</div>
<div class="field-type-text field-name-field-podiatrist-last-name field-widget-text-textfield form-wrapper form-group" id="edit-field-podiatrist-last-name">
<div id="field-podiatrist-last-name-add-more-wrapper">
<div class="form-item form-item-field-podiatrist-last-name-und-0-value form-type-textfield form-group"> <label class="control-label" for="edit-field-podiatrist-last-name-und-0-value">Podiatrist Last Name <span class="form-required"
title="This field is required.">*</span></label>
<input class="text-full form-control form-text required" type="text" id="edit-field-podiatrist-last-name-und-0-value" name="field_podiatrist_last_name[und][0][value]" value="" size="60" maxlength="255">
</div>
</div>
</div>
<div class="field-type-text field-name-field-podiatrist-address field-widget-text-textfield form-wrapper form-group" id="edit-field-podiatrist-address">
<div id="field-podiatrist-address-add-more-wrapper">
<div class="form-item form-item-field-podiatrist-address-und-0-value form-type-textfield form-group"> <label class="control-label" for="edit-field-podiatrist-address-und-0-value">Podiatrist Address (Including Practice Company Name, Street,
City, State, Zip) <span class="form-required" title="This field is required.">*</span></label>
<input class="text-full form-control form-text required" title="" data-toggle="tooltip" type="text" id="edit-field-podiatrist-address-und-0-value" name="field_podiatrist_address[und][0][value]" value="" size="60" maxlength="255"
data-original-title="Street Address, City, State, Zip">
</div>
</div>
</div>
<div class="field-type-phone field-name-field-podiatrist-phone field-widget-phone-textfield form-wrapper form-group" id="edit-field-podiatrist-phone">
<div id="field-podiatrist-phone-add-more-wrapper">
<div class="form-item form-item-field-podiatrist-phone-und-0-value form-type-textfield form-group"> <label class="control-label" for="edit-field-podiatrist-phone-und-0-value">Podiatrist Phone <span class="form-required"
title="This field is required.">*</span></label>
<input class="form-control form-text required" type="text" id="edit-field-podiatrist-phone-und-0-value" name="field_podiatrist_phone[und][0][value]" value="" size="17">
</div>
</div>
</div>
<div class="field-type-markup field-name-field-specifics field-widget-markup form-wrapper form-group" id="edit-field-specifics">
<div id="field-specifics-add-more-wrapper">
<div class="row">
<div class="col-sm-12">
<h3>SPECIFICS OF YOUR COMPLAINT:</h3>
<hr>
<p>On the following line please summarize in one sentence the concern you have regarding the podiatrist:</p>
</div>
</div>
</div>
</div>
<div class="field-type-text field-name-field-short-summary-of-complaint field-widget-text-textfield form-wrapper form-group" id="edit-field-short-summary-of-complaint">
<div id="field-short-summary-of-complaint-add-more-wrapper">
<div class="form-item form-item-field-short-summary-of-complaint-und-0-value form-type-textfield form-group"> <label class="control-label" for="edit-field-short-summary-of-complaint-und-0-value">Short summary of complaint</label>
<input class="text-full form-control form-text" type="text" id="edit-field-short-summary-of-complaint-und-0-value" name="field_short_summary_of_complaint[und][0][value]" value="" size="60" maxlength="255">
</div>
</div>
</div>
<div class="field-type-markup field-name-field-complaint field-widget-markup form-wrapper form-group" id="edit-field-complaint">
<div id="field-complaint-add-more-wrapper">
<div class="row">
<div class="col-sm-12">
<h3>YOUR COMPLAINT</h3>
<hr>
<p><b>PLEASE SUMMARIZE IN DETAIL YOUR CONCERNS REGARDING THIS PODIATRIST.</b><em>Include the dates of key events, as well as names of people (including how we might contact them) who may have information helpful to the Board of Podiatry
Examiners. Also include any other information which you feel may be helpful to the Board.(You may attach additional pages, if needed.)</em></p>
</div>
</div>
</div>
</div>
<div class="field-type-text-with-summary field-name-field-complaint-main field-widget-text-textarea-with-summary form-wrapper form-group" id="edit-field-complaint-main">
<div id="field-complaint-main-add-more-wrapper">
<div class="text-format-wrapper">
<div class="text-summary-wrapper"></div>
<div class="form-item form-item-field-complaint-main-und-0-value form-type-textarea form-group"> <label class="control-label" for="edit-field-complaint-main-und-0-value">Complaint</label>
<div class="form-textarea-wrapper resizable textarea-processed resizable-textarea"><textarea class="text-full wysiwyg form-control form-textarea" id="edit-field-complaint-main-und-0-value" name="field_complaint_main[und][0][value]"
cols="60" rows="20"></textarea>
<div class="grippie"></div>
</div>
</div>
<fieldset class="filter-wrapper form-inline panel panel-default form-wrapper" id="edit-field-complaint-main-und-0-format">
<div class="panel-body" id="edit-field-complaint-main-und-0-format-body">
<div class="filter-help form-wrapper form-group" id="edit-field-complaint-main-und-0-format-help"><a href="/filter/tips" target="_blank" title="" data-toggle="tooltip" data-original-title="Opens in new window"><span class="icon glyphicon glyphicon-question-sign" aria-hidden="true"></span>
More information about text formats</a></div>
</div>
</fieldset>
</div>
</div>
</div>
<div class="field-type-file field-name-field-attachment field-widget-file-generic form-wrapper form-group" id="edit-field-attachment">
<div id="edit-field-attachment-und-ajax-wrapper">
<fieldset id="edit-field-attachment-und" class="panel panel-default form-wrapper">
<legend class="panel-heading">
<span class="panel-title fieldset-legend">Attachment</span>
</legend>
<div class="panel-body" id="edit-field-attachment-und-body">
<div class="form-item form-item-field-attachment-und-0 form-type-managed-file form-group"> <label class="control-label" for="edit-field-attachment-und-0">Add a new file</label>
<div class="file-widget form-managed-file clearfix input-group"><input type="hidden" name="field_attachment[und][0][_weight]" value="0">
<input type="hidden" name="field_attachment[und][0][fid]" value="0">
<input type="hidden" name="field_attachment[und][0][display]" value="1">
<input class="form-control form-file" type="file" id="edit-field-attachment-und-0-upload" name="files[field_attachment_und_0]" size="22"><span class="input-group-btn"><button
class="btn-primary btn form-submit icon-before ajax-processed" type="submit" id="edit-field-attachment-und-0-upload-button" name="field_attachment_und_0_upload_button" value="Upload"><span class="icon glyphicon glyphicon-upload"
aria-hidden="true"></span> Upload</button>
</span>
</div>
<div class="help-block"><a href="#" data-toggle="popover" data-target="#upload-instructions" data-html="1" data-placement="bottom" data-title="File requirements" data-original-title="" title=""><span class="icon glyphicon glyphicon-question-sign" aria-hidden="true"></span>
More information</a>
<div id="upload-instructions" class="element-invisible help-block">
<ul>
<li>Files must be less than <strong>2 MB</strong>.</li>
<li>Allowed file types: <strong>jpg jpeg gif png txt doc docx xls xlsx pdf ppt pptx pps ppsx odt ods odp mp3 mov mp4 m4a m4v mpeg avi ogg oga ogv weba webp webm tiff</strong>.</li>
</ul>
</div>
</div>
</div>
</div>
</fieldset>
</div>
</div>
<div class="field-type-markup field-name-field-space field-widget-markup form-wrapper form-group" id="edit-field-space">
<div id="field-space-add-more-wrapper"></div>
</div>
<div class="field-type-serial field-name-field-case-number- field-widget-serial-widget-default form-wrapper form-group" id="edit-field-case-number-">
<div id="field-case-number-add-more-wrapper"><input type="hidden" name="field_case_number_[und][0][value]" value="">
</div>
</div>
<div class="field-type-markup field-name-field-disclaimer field-widget-markup form-wrapper form-group" id="edit-field-disclaimer">
<div id="field-disclaimer-add-more-wrapper">
<h2>Terms and Conditions</h2>
<p>Please note that use of this online complaint submission process forwards your information and documents to a document-sharing portal that is secured with login and password accessible only to individuals appointed by the Board.</p>
<p>You are acknowledging by your submission of the information included in your complaint and any attachments, including any otherwise personal information and/or protected health information, that all such information will be reviewed as
part of the investigation and possible, disciplinary process, and by your signature acceptance below you are expressly authorizing the sharing of this information with members of the Board’s Grievance Committee, Board Counsel, Board Staff,
Board Members, and the Respondent (podiatrist about whom you are complaining) as may be necessitated by the investigation and possible disciplinary process.</p>
</div>
</div>
<div class="field-type-list-boolean field-name-field-agree-with-terms field-widget-options-onoff form-wrapper form-group" id="edit-field-agree-with-terms">
<div class="form-item form-item-field-agree-with-terms-und form-type-checkbox checkbox"> <label class="control-label" for="edit-field-agree-with-terms-und"><input type="checkbox" id="edit-field-agree-with-terms-und"
name="field_agree_with_terms[und]" value="1" class="form-checkbox">I agree with the terms above</label>
</div>
</div>
<h2 class="element-invisible">Vertical Tabs</h2>
<div class="vertical-tabs-panes vertical-tabs-processed tab-content"><input class="vertical-tabs-active-tab" type="hidden" name="additional_settings__active_tab" value="">
</div>
<div class="form-actions form-wrapper form-group" id="edit-actions"><button type="submit" id="edit-submit" name="op" value="Submit" class="btn btn-success form-submit icon-before"><span class="icon glyphicon glyphicon-ok"
aria-hidden="true"></span> Submit</button>
<button type="submit" id="edit-preview" name="op" value="Preview" class="btn btn-default form-submit">Preview</button>
</div>
</div>
</form>Text Content
Skip to main content Toggle navigation * Complaint Form CREATE COMPLAINT This form is designed to assist you in filing a complaint regarding a podiatrist (DPM). You will assist the North Carolina Board of Podiatry Examiners in investigating your complaint by providing as much of the requested information as possible. You may upload or attach any additional pages or other information relating to your complaint. YOUR INFORMATION: -------------------------------------------------------------------------------- Complainant First Name * Complainant Last Name * Complainant Full Address (Street, City, State, Zip) * Complainant Telephone (Home/Mobile) * Complainant Telephone (Work) Email * PLEASE CHECK THE APPROPRIATE BOX * The Board of Podiatry Examiners has my permission to share this complaint with the podiatrist named below. The Board of Podiatry Examiners does not have my permission to share this complaint with the podiatrist named below. Please note: If this complaint cannot be shared with the podiatrist, the Board will accept it as information only and no further action may be taken. CONTACT INFORMATION FOR THE PODIATRIST (ABOUT WHOM THE COMPLAINT IS MADE): -------------------------------------------------------------------------------- Podiatrist First Name * Podiatrist Last Name * Podiatrist Address (Including Practice Company Name, Street, City, State, Zip) * Podiatrist Phone * SPECIFICS OF YOUR COMPLAINT: -------------------------------------------------------------------------------- On the following line please summarize in one sentence the concern you have regarding the podiatrist: Short summary of complaint YOUR COMPLAINT -------------------------------------------------------------------------------- PLEASE SUMMARIZE IN DETAIL YOUR CONCERNS REGARDING THIS PODIATRIST.Include the dates of key events, as well as names of people (including how we might contact them) who may have information helpful to the Board of Podiatry Examiners. Also include any other information which you feel may be helpful to the Board.(You may attach additional pages, if needed.) Complaint More information about text formats Attachment Add a new file Upload More information * Files must be less than 2 MB. * Allowed file types: jpg jpeg gif png txt doc docx xls xlsx pdf ppt pptx pps ppsx odt ods odp mp3 mov mp4 m4a m4v mpeg avi ogg oga ogv weba webp webm tiff. TERMS AND CONDITIONS Please note that use of this online complaint submission process forwards your information and documents to a document-sharing portal that is secured with login and password accessible only to individuals appointed by the Board. You are acknowledging by your submission of the information included in your complaint and any attachments, including any otherwise personal information and/or protected health information, that all such information will be reviewed as part of the investigation and possible, disciplinary process, and by your signature acceptance below you are expressly authorizing the sharing of this information with members of the Board’s Grievance Committee, Board Counsel, Board Staff, Board Members, and the Respondent (podiatrist about whom you are complaining) as may be necessitated by the investigation and possible disciplinary process. I agree with the terms above VERTICAL TABS Submit Preview 3739 National Drive, Suite 202 Raleigh, NC 27612 • Phone: (919) 861-5583 • Fax: (919) 787-4916 • Email: info@ncbpe.org Copyright © 2024 The North Carolina Board of Podiatry Examiners. All rights reserved.