F-0043Doctor's first report
Physician's first report: subjective/objective findings, diagnosis, treatment plan and follow-up.
- Completed by
- Physician
- Issued by
- Yukon Workers' Safety and Compensation Board
- Format
- Fillable PDF
- Language
- English
Yukon WSCB Dentist's First Report (F-0103)
Yukon dentists complete this one-page WSCB report when a worker's teeth or dentures are damaged in a work-related incident. It records the worker's account of the mechanism and complaints, who gave initial treatment, the damage, a tooth chart, other oral conditions and the diagnosis. WSCB pays for emergency dental treatment, but further treatment must be authorized before it goes ahead.
Who completes it
The treating dentist completes and signs the whole form and attaches the treatment plan and itemized estimate. The worker completes no part of it.
Submitting and payment
- How to submit it
- Fax the report to WSCB at the number printed on it, with the treatment plan, the itemized estimate and any X-ray report; Yukon's Act requires health care providers to report within two days of first attending an injured worker.
- Who pays
- WSCB pays for emergency dental treatment, and further work is paid once authorized, based on an estimate itemized from the Yukon Dental Association Fee Schedule.
Good to know
- Mark the chart with A for teeth damaged by the accident, E for teeth to be extracted and X for teeth missing before the accident.
- If necessary, X-ray the injured areas and submit the X-ray report to WSCB along with the form.
- The treatment plan should restore the worker's oral function, as nearly as possible, to the degree that existed before the incident.
- Health care providers treating injured workers need a WSCB service agreement, applied for through the Yukon Health Care Provider Application (F-0198).
Get the official form
Download the current version from the source each time; forms change without notice.
Dentist's first report
Fill it with Vero
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.
How this list is checked
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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Frequently asked questions
Does Yukon WSCB pay for emergency dental treatment?
Yes. The Dentist's first report states that WSCB pays for emergency dental treatment. Authorization for further dental services must be obtained before proceeding with additional treatment, so attach a detailed treatment plan and an estimate itemized using the Yukon Dental Association Fee Schedule when you fax the report.
What do I attach to the Yukon dentist's first report?
Two items, returned by fax: a detailed treatment plan to restore oral function as nearly as possible to its pre-incident state, and a detailed estimate with charges itemized using the Yukon Dental Association Fee Schedule. If you X-rayed the injured areas, submit the X-ray report to WSCB as well.
How is the tooth chart marked on F-0103?
Use A for teeth damaged by the accident, E for teeth to be extracted and X for teeth missing before the accident. The form also asks you to describe the damage resulting from the injury, including any damage to dentures, and any other oral condition, with your opinion on whether it is due to the incident.