Please Provide As Much of the Information Listed on this Form
* Required Information is noted with an asterisk and yellow form field*

For complaints about unsanitary conditions at restaurants or
food borne illness contact The Department of Business and Professional Regulations.

* Incident Date:  

* Today's  Date:

Complaint Information
Business Name: 
Owner Name:
* Nuisance Address
* Nuisance City
State:
Zip Code
Phone
Occupant
Occupant Address
Occupant City
Occupant State
Zip Code
Occupant Phone
Your Information
First Name
Last Name
Address
City
State
Zip Code
Phone
Email
Cell Phone

To protect your privacy, please do not disclose or share any sensitive or confidential health and financial related information within this form. Instead, contact this office by phone or in writing.

* Location of the nuisance
Example: Back of the house near the alley

Please be Specific

* Choose the type of complaint, or choose other if not listed
 

* Describe the Nuisance *

Please be Specific

To submit your complaint, re-type the numbers located in the box into the blank box, and click submit. 


Department of Health Mission: To protect, promote & improve the health of all people in Florida through integrated state, county, & community efforts.  

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