Online Complaint Form: Tattoo or Piercing Facility

Instructions: Please enter as much information as possible. Items with * are required fields. Any information you provide is confidential. You may choose to remain anonymous however please enter a valid e-mail address and telephone number in case we need to contact you for additional information. When you are finished click the "Submit" button. If you prefer, you may file a complaint by phone at (716) 961-6800. Thank you.

Name of Tattoo/Piercing Facility

Tattoo/Piercing Facility Address

City/Town

State/Province

ZIP/Postal Code

Name/Description of Tattoo/Piercing Artist

Date and Time You Observed the Problem

Description of Problem

Your First Name

Your Last Name

Your Telephone Number

Your Email Address