STATEMENT REGARDING

INJURIES SUSTAINED
1981 McGill Avenue, Suite 100
Montreal (Quebec) H3A 3A7

SECTION TO BE COMPLETED AND SIGN BY THE CARDHOLDER (Please answer all the following questions)
CARDHOLDER ACCIDENT
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Policy No : Identification N : Date :
Family Name : Where :
Given Name : Circumstances :

INJURED PERSON
Family Name :
Given Name :
Address :
OTHER INSURANCE
Will another insurance policy cover, in whole or in part, the dental
expenses incurred as a result of this accident ?
Date of Birth : / / Yes No
D M Y If yes, which insurance ?

I hereby declare that all the information stated on this document are, to be best of my knowledge, complete, accurate and true.

Date Cardholder’s signature

SECTION TO BE COMPLETED BY THE DENTIST (Please answer all the following questions)
IDENTIFICATION OF THE AFFECTED TEETH CONDITION OF EACH TOOTH TREATED
 Which are the teeth implied in the accident ? AS A RESULT OF THE ACCIDENT
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(Tooth N ) a) Was there any dental caries and/or defective restorations ?

 For each of these teeth, please provide the clinical description of

the traumatism as a result of the accident :

X-RAYS AS THE RESULT OF DENTAL INJURIES b) Was the periodontal tissue healthy ?
 Please provide the X-Rays carried out
before the treatment but after the accident.
NOTICE : Not dated X-Rays, duplicates, and/or not identified
c) Was there any periapical lesion ?
photographs left-right-hand side and/or not dated
will not be considered.

OTHER INJURIES (lesions, cut or fractures) IDENTIFICATION OF THE DENTIST

Please specify nature of injury :
Name :
Address :

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Licence N :
COMMENTS

I hereby declare that all the information stated on this document are, to be best of my knowledge, complete, accurate and true.

Date Dentist’s signature