PATIENT REQUEST FOR MEDIATION

When a problem arises, patients should:

Talk to your dentist in an effort to resolve the problem. If speaking to the dentist does not resolve the issue a complaint may be filed through the Virginia Dental Association if the dentist in question is a member of the VDA.
Click HERE to search our membership list to determine if your dentist is a member. If the dentist in question is NOT a VDA Member, please file complaints through the Virginia Board of Dentistry.

Utilization of the Patient Request For Mediation Form is a process to try to resolve a disagreement about dental treatment that a patient and a dentist have not been able to resolve themselves. The peer review process begins at the local level (component) where a complaint is reviewed by our Patient Relations & Peer Review Committee. This committee is established to review matters concerning, but not limited to, appropriateness of care, quality of care, and sometimes, when acting in an advisory capacity, fees.

The peer review process was not designed to handle every type of situation. It cannot consider cases in litigation, dentist-to-dentist complaints, alleged fraud, and other violations of State Dental Practice Acts.

All requests/complaints must be made in writing through the online form below.

Confidential

Upon receipt of this completed form a mediator will be assigned and will contact you to discuss your request and help resolve the issue. While a refund of a fee you 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 with this form.

By submitting this form you are saying that you agree with the following statement (Submission of this form will serve as your electronic signature):

In order for a complete review to be performed, I authorize the release to this committee, for any dental records or information by anyone who has examined me previously. I further give my permission for the committee to perform a clinical examination if necessary.

First Name *

Last Name *

Address *

City, State Zip Code *

Phone *

xxx-xxx-xxxx

Best time to be reached by phone

Morning
Lunch Time
Afternoon
Evening
Anytime

Email Address *

Name of Dentist *

Dentist Address *

Dentist City, State Zip Code *

Dentist Phone Number *

Date of Last Appointment *

MM/DD/YYYY

Please Describe the problem(s) specific to the dental treatment received. *