TIA-SOP Intake form

Please fill out the form below to submit an issue of concern to the Academy regarding truth-in-advertising and/or scope of practice. 

Full name
Please provide your contact information (phone and/or email)
In what state do you practice?
In what state did the incident occur?
Are you a member of your state dermatology society?
Identify the type of provider at issue
Nature of complaint: Please describe with as much detail as possible
Name of the practice in question
Are you aware of a patient injury?
Have you contacted the medical society and/or your state dermatology society?
Have you contacted an enforcement agency (e.g., medical board, attorney general)?