After a work-related dental injury in New Brunswick, the attending dentist or denturist completes this one-page estimate and forwards it promptly to WorkSafeNB. It records the date of incident, a tooth chart of teeth damaged by the incident and teeth already missing, a detailed description of the damage, and itemized procedure codes with laboratory charges and professional fees.
The attending dentist or denturist completes, stamps and signs the form, including the worker's details and Medicare number and the employer's name and address. The worker does not sign it.
Download the current version from the source each time; forms change without notice.
Estimate of Required Dental Services
Coût estimatif des services dentaires requis
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.
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The attending dentist or denturist. The form says it is to be completed by them and forwarded promptly to WorkSafeNB, printed clearly, then signed and stamped with the dentist or denturist's details and their payee code.
Use the tooth chart: mark each tooth damaged by the workplace incident with the letter A, and each tooth that was missing before the incident with the letter M. Then itemize the procedure code, tooth number, laboratory charge, professional fee and total charge for each treatment.
Yes. WorkSafeNB posts Coût estimatif des services dentaires requis on its French-language site, travailsecuritairenb.ca. The English version is the only form listed for dentists on WorkSafeNB's health care forms page, which also sets out the MyServices, fax and mail submission options.