Dentists treating a work-related dental injury for a WSCC claimant in the Northwest Territories or Nunavut complete this two-page report and estimate. It records the worker's account of the cause, the damage (including to dentures), a tooth chart, other oral conditions and whether they relate to the incident, and a plan to restore chewing function as nearly as possible to its pre-accident level, with an itemized cost estimate.
The treating dentist completes both sides, including the tooth chart, treatment plan and itemized estimate, and signs as the health care provider. The worker and employer do not complete any part.
Download the current version from the source each time; forms change without notice.
If your copy of the form is a fillable PDF, upload it 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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No. Question 8 asks you to estimate the entire treatment plan with itemized charges using your Dental Association Fee Schedule, but the form states it is an estimate only and not to be considered an account. Invoices go separately to WSCC Financial Services on the WSCC Medical Invoice form.
The Nunavut and NWT Workers' Compensation Acts excerpt printed on the form says a health care provider who examines or treats a worker must submit a report within three days after the examination or treatment. If a health care facility employs you, the facility is responsible for making sure the report is submitted.
Yes. WSCC publishes the Dental Report and Estimate in both English and French, and the English form notes that a French version is available. Both versions are print-and-complete PDFs with the same tooth chart, and the same form serves workers in the Northwest Territories and Nunavut.