Dental accident report form 2025

1. Click ‘Get Form’ to open the dental accident report form in the editor.
2. Begin by entering the patient’s name, Green Shield I.D. number, address, relationship to the plan member, city/prov/postal code, email address, and phone number in the designated fields.
3. In the Mandatory Declaration section, indicate if there is any other group insurance coverage that may include these services as benefits by selecting 'Yes' or 'No'. If applicable, provide the insurance company name and Green Shield Canada ID Number.
4. Specify if treatment is required due to a motor vehicle accident or a work-related injury by selecting 'Yes' or 'No'.
5. Fill in the date of the accident (year, month, day) and provide details about how the accident occurred in the description field.
6. The plan member must sign and date the form to authorize information release.
7. The treating dentist will complete their section by providing their name, unique number, address, signature, and phone number. They should also describe any damage including tooth numbers.
8. Finally, ensure all necessary documents such as x-rays are attached before submitting your completed form.

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