Medical Emergency Incidence Form

Reported by: _________________________________ Date of Incident: ____________________

Name of Supervising Dentist: __________________________

Designation:

Department: _______________________________

Witnessed: Yes ______ No ______ By: ______________________________ Title: ________________

NAME OF PATIENT AND/OR OTHERS INVOLVED: ___________________________________

Other (specify) ______________________________________________________________

TYPE OF MEDICAL EMERGENCY:

Was the response team notified: Yes_____ No _____

Did the dentist examine the patient post incident: Yes ____ No ____

Describe briefly what happened:

Describe the treatment provided:

What action has or needs to be taken to prevent recurrence?

Signature of Person Reporting Incident