Quack Doctors List

Complainant's Full Name *

Complainant's Email *

Complainant's Phone(Optional)

Complain Details*

Affidavit *(eg scanned doc in pdf,png,jpg or gif) Image size:Width:1,900px Height:1,500px)

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Reporter's Name *

Reporter's Email *

Reporter's Phone(Optional)

Details of Complain*

Suspect's Name *

Suspect's Gender -- Select One -- Male Female Others (School or Hospital)

Suspect's Address *

Suspect's State - Select State - Abia Adamawa Akwa Ibom Anambra Bauchi Bayelsa Benue Borno Cross River Delta Ebonyi Edo Ekiti Enugu FCT Gombe Imo Jigawa Kaduna Kano Katsina Kebbi Kogi Kwara Lagos Nasarawa Niger Ogun Ondo Osun Oyo Plateau Rivers Sokoto Taraba Yobe Zamfara

Suspect's LGA

Date of Incident *(eg. MM/DD/YYYY)

Suspect's Category -- Select One -- Personnel School Hospital

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