MDA Webforms | Animal-Health-Complaint-Submittal

Please DO NOT include any personal, confidential, and/or sensitive information in your responses on this form (e.g. social security number, credit card information, health information, account number, etc.).

Complainant Information

Prefix

Last Name *

First Name *

Middle Initial

Suffix

Business Name

Address 1 *

Address 2

City *

State *

County

Zip Code *

zip plus four -

Primary Phone *

Phone Type Ext.

Alternate Phone 1

Phone Type Ext.

Alternate Phone 2

Phone Type Ext.

Alternate Phone 3

Phone Type Ext.

E-mail Address

Confirm E-mail Address

Subject of Complaint

Provide the full name and address of the person/business against whom you are filing this complaint.

Prefix

Last Name *

First Name *

Middle Initial

Suffix

Name of Business

Address 1 *

Address 2

City *

State *

County

Zip code*

Zip Code - zip plus four

Primary Phone

Phone Type Ext.

Phone 1

Phone Type Ext.

Phone 2

Phone Type Ext.

Phone 3

Phone Type Ext.

Details of Complaint

Species

Please state your complaint briefly and clearly, noting specific violations of the law. *

Witness

Provide full names and addresses of any other persons/witnesses who can verify the facts alleged.

Prefix

Last Name

First Name

Middle Initial

Suffix

Address 1

Address 2

City

State

Zip code

Zip Code - zip plus four

County

Primary Phone

Phone Type Ext.

Upload

Attach copies of documents (bills, correspondence, pictures, etc.) that would substantiate your complaint.

Upload Name
JPEG , JPG , PDF

Number of uploads

Signature

I accept the terms and conditions Required

Legal Name*

Date 04/15/2026

Animal Health Complaint Submittal

Provide the full name and address of the person/business against whom you are filing this complaint.

Provide full names and addresses of any other persons/witnesses who can verify the facts alleged.

Attach copies of documents (bills, correspondence, pictures, etc.) that would substantiate your complaint.