Regulation and standards for denturists in Sakatchewan

Your Information

Name(Required)

First Last

Address(Required)

Street Address City Province Postal Code

Phone(Required)

Email(Required)

Communication preference:(Required)

Email: I choose email as my main communication preference. Send complaint correspondence to the email address provided above. I consent to receive information via email from the Society and its representatives for the purposes of this complaint.

Canada Post: I choose mail as my main communication preference. Send complaint correspondence to the mailing address provided above.

Representative Information

If you are a representative of the complainant, please provide your details, attach any authorizing documentation, and have the complainant sign the authorization below.

Do you have any representative Information to add here?(Required)

No

Yes

Name

First Last

Address

Street Address City Province Postal Code

Phone

Email

Relationship to Complainant (e.g. guardian, power of attorney, legal counsel):

File

Max. file size: 10 MB.

File

Max. file size: 10 MB.

Complainant Signature(Required)

Denturist Information

Denturist Name(Required)

First Last

Clinic Name

Address(Required)

Street Address City Province Postal Code

Phone(Required)

Your Concern

Provide a clear description of the concern you have about the denturist who you have identified. In your description, include what the denturist did, or failed to do, to cause you to contact the Society:

a) what happened
b) where it happened; and
c) when it happened (in chronological order).

Please include as much detail as possible.(Required)

Witness Information

Please identify any individual(s), if applicable, who may have information about the incident (e.g., staff, family).

Full name

First Last

Address

Street Address City State / Province / Region ZIP / Postal Code

Phone

Email

Information they may have:

Full name

First Last

Address

Street Address City State / Province / Region ZIP / Postal Code

Phone

Email

Information they may have:

Full name

First Last

Address

Street Address City State / Province / Region ZIP / Postal Code

Phone

Email

Information they may have:

What do you hope will happen as a result of your complaint?

NOTE: If you have been advised to contact the Society to obtain a refund from a denturist, this is only possible where a complaint is investigated and a prima facie case of professional incompetence or professional misconduct is established or the denturist has been found guilty of professional incompetence or professional misconduct by the discipline committee.(Required)

Relevant documents or evidence to support your concern.

Submit copies with this form or via email to regulatoryadmin@saskdenturists.com

File

Max. file size: 10 MB.

1. The denturist, as named above will be notified of my complaint, and will be provided a copy of this submitted form.
2. The Denturist Society of Saskatchewan may collect, use and/or disclose the patient’s/my personal health information, such as diagnostic, treatment, and patient care information when relevant, and if this matter is investigated any information collected during an investigation will be used for the Denturist Society of Saskatchewan professional conduct process.
3. Your information may only be disclosed in accordance with the The Health Information Protection Act or with your consent.

Complainant/Representative Signature(Required)

Date signed (mm/dd/yyyy)(Required)

Your Privacy is Important to Us

We collect, use and/or disclose your personal information as authorized or required by legislation or with your consent, in order to regulate the denturist profession in the public interest.

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Complaint Form

Your Information

Representative Information

Denturist Information

Your Concern

Witness Information

What do you hope will happen as a result of your complaint?

Relevant documents or evidence to support your concern.

Your Privacy is Important to Us