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
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Dr.
Mr.
Mrs.
Ms.
Last Name
*
First Name
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Middle Initial
Suffix
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III
IV
Jr.
Sr.
Business Name
Address 1
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Address 2
City
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State
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County
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Adair
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Audrain
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Christian
Clark
Clay
Clinton
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Dade
Dallas
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De Kalb
Dent
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Henry
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Holt
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Iron
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Jasper
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Linn
Livingston
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Madison
Maries
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Mercer
Miller
Mississippi
Moniteau
Monroe
Montgomery
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New Madrid
Newton
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Oregon
Osage
Ozark
Pemiscot
Perry
Pettis
Phelps
Pike
Platte
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Pulaski
Putnam
Ralls
Randolph
Ray
Reynolds
Ripley
Saline
Schuyler
Scotland
Scott
Shannon
Shelby
St. Charles
St. Clair
St. Francois
St. Louis
St. Louis City
Ste. Genevieve
Stoddard
Stone
Sullivan
Taney
Texas
Vernon
Warren
Washington
Wayne
Webster
Worth
Wright
Zip Code
*
Ext.
-
Primary Phone
*
Phone Type
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C-Cell
H-Home
O-Office
Ext.
Alternate Phone 1
Phone Type
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C-Cell
F-Fax
H-Home
O-Office
Ext.
Alternate Phone 2
Phone Type
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C-Cell
F-Fax
H-Home
O-Office
Ext.
Alternate Phone 3
Phone Type
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C-Cell
F-Fax
H-Home
O-Office
Ext.
E-mail Address
Confirm E-mail Address
email and confirm email do not match
Subject of Complaint
Provide the full name and address of the person/business against whom you are filing this complaint.
Prefix
Select
Dr.
Mr.
Mrs.
Ms.
Last Name
*
Last Name
First Name
*
Middle Initial
Suffix
Select
III
IV
Jr.
Sr.
Name of Business
Address 1
*
Address 2
City
*
State
*
Select
Missouri
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip code
*
Zip Code
-
Ext
County
Primary Phone
primary phone
Phone Type
Select
C-Cell
H-Home
O-Office
Ext.
Phone 1
Alternate Phone 1
Phone Type
Select
C-Cell
F-Fax
H-Home
O-Office
Ext.
Phone 2
Alternate Phone 2
Phone Type
Select
C-Cell
F-Fax
H-Home
O-Office
Ext.
Phone 3
Alternate Phone 3
Phone Type
Select
C-Cell
F-Fax
H-Home
O-Office
Ext.
Details of Complaint
Species
Please state your complaint briefly and clearly, noting specific violations of the law.
*
details of inquiry
Witness
Provide full names and addresses of any other persons/witnesses who can verify the facts alleged.
Prefix
Select
Dr.
Mr.
Mrs.
Ms.
Last Name
First Name
Middle Initial
Suffix
Select
III
IV
Jr.
Sr.
Address 1
Address 2
City
State
Select
Missouri
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip code
Zip Code
-
Ext
County
Primary Phone
primary witness phone
Phone Type
Select
C-Cell
F-Fax
H-Home
O-Office
Ext.
Upload
Attach copies of documents (bills, correspondence, pictures, etc.) that would substantiate your complaint.
Upload Name
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Signature
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Legal Name
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Date 12/12/2024
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