Peer Review Application

Peer Review Application Form

You may enter your information online and apply for a peer review on your behalf by the Kansas Dental Association.

Do you have a case pending with the Kansas Dental Board concerning this case?

Yes
No

Date

date/month/year

Salutation

Patient Name

First, Last

Patient Phone

May we contact you via email regarding this case?

Yes
No

Patient Address

(Street, City, State , ZIP)

Dentist Information

Dentist Name

Dentist Email

email@me.com

Dentist Address

(Street, City, State , ZIP)

Have you contacted the dentist office about your concerns?

When was your last appointment with the dentist?*

(Day, Month, Year)

Please describe the problem(s) specific to the dental treatment received. While a refund of any charges you may have paid is one of the options that may be recommended by the mediator, a request for a refund should not be made in writing or on this form.*

I certify that I am at least 18 years old and am the patient or the parent/legal guardian of the patient. In order that a complete review be performed, I understand that I must authorize the release of any dental records or information by anyone who has examined the patient, previously, to the Kansas Dental Association Council on Peer Review.*

(Sign Your Name First, Last)

Peer Review Application Form

Dentist Information

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