1.Date, time, and place prohibited activity occurred:*
2.Prohibited activity that took place:*
3.Any persons/entities (other than those named above) who were involved in the prohibited activity:*
4.The names of any other witnesses (a consumer, regulatory agency, licensed optician or apprentice, or anyone else with knowledge of the alleged violation):
5.Any documentation that supports the complaint (e.g. a witness statement or patient record); please attach copies:
*I certify, under penalty of perjury, all information given here in is true, correct and complete to the best of my knowledge.