Veterinary Surgeons Board of South Australia

Email: admin@vsbsa.org.au

Phone: +61 8 8331 9433

Fax: +61 8 8364 4688

185 Fullarton Road,

Dulwich SA 5065

*Required Fields.

PERSON MAKING THE COMPLAINT—OWNER OF ANIMAL
*Name
Owner of animal	Yes
*Name of Owner (if not person making the complaint)
*Address
Telephone Number
Email (if applicable)

PERSON WHO PRESENTED THE ANIMAL TO THE VETERINARIAN
Tick the box if same as above	Yes
(if not, please provide details)
*Name
*Address
Telephone
Email (if applicable)

ABOUT THE ANIMAL
*Name
Age
Sex
*Type of animal (dog, cat, bird etc)
Breed
Markings
color

ABOUT THE VETERINARIAN
*Name of the Vet
*Name of Vet Clinic or Hospital
*Address
*Date on which the incident which is the subject of the complaint occurred

Declaration
I understand that my letter detailing the complaint will be sent to the veterinarian. I give permission for the release of the clinical records of the animal to the Board. (Cross out if not applicable). If a second veterinarian was involved in the care of my animal, I give permission for that veterinarian to comment on the case, and provide clinical records to the Board.
*Name	Date
If a person other than the person making the complaint presented the animal to the veterinarian, if possible, please ask them to sign here to verify that the following statement is correct.
*Name	Date
The following sections are important in assisting the Veterinary Surgeons Board of SA to clearly understand your main concerns and to ensure all issues are addressed.
*SPECIFIC ISSUES YOU WISH TO BE ADDRESSED

* WHAT DO YOU HOPE TO ACHIEVE FROM THIS INVESTIGATION
(e.g. better understanding of what happened and why; apology from the vet; reduction in cost of service*; formal investigation into veterinarian etc)

* Please note the Veterinary Surgeons Board of SA is not able to enquire into the fees charged by veterinarians, except in circumstances where the fees charged significantly exceed the quoted price (see page 2 for information on matters the Board is able to enquire into).