A Manitoba dentist sends this two-page report when treating a worker's dental injury from a workplace accident. One form covers three situations: the initial report, a change in treatment, and WCB re-treatment when earlier WCB-funded work has failed. It combines dental charting, diagnosis, mechanism of injury and TMJ findings with a fee breakdown of treatment to date and proposed future treatment.
The dentist completes the whole report and signs a declaration that the injuries result from the workplace incident, that treatment only restores that damage, and that it is within their scope of practice. The worker does not sign.
Download the current version from the source each time; forms change without notice.
Upload the fillable PDF once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms change without notice, so download the current version from the official page before you fill it in.
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The declaration certifies that the dental injuries result from a workplace injury or are consistent with one, that proposed treatment is solely to restore that damage or a re-treatment failure, that the treatment fits the patient's pre-accident status and standard of dental care, and that you are working within your scope of practice and training.
The enclosures section notes that an Oral Health Certificate is required for complete dentures and a prescription is required for partial dentures. WCB Manitoba pays denture work at Denturist Association fee guide rates, and only for the procedure codes it has approved.
Lab charges and expense fees are listed separately on the report, marked L and E, for both treatment to date and proposed treatment, and the form asks you to forward copies of itemized lab charges and expense fees. Where applicable, a copy of the lab report must accompany the invoice.