Dental Office Incident Report printable pdf download

Dental Office Incident Report

An Incident Report Should Be Filed Within 48 Hours

Reported by: _________________________________ Date of Incident: ____________________ Date: ____________________

Dental Office: ____________________________________ Name of Supervising Dentist (print): __________________________

Office Address: _________________________________________________________________________________________

City: ___________________________________________ Prov: ______________________ P.C.:_________________________

Type of Incident: __________________________________________________________________________________________

Witnessed: Yes ______ No ______

By: ______________________________ Title: _____________________________

NAME OF CLIENT AND/OR OTHERS INVOLVED: ______________________________________________________________

CLASSIFICATION:

Verbal Abuse: ________ Physical Abuse: ________ Treatment Error: ________ Injury: ________

Equipment Error: ________ Unsafe Working Environment: ________ Sharp Injury: ________

Other (specify) ______________________________________________________________________

TYPE OF INCIDENT: (attach additional sheets as required)

Was the dentist notified: Yes_____ No _____ Did the dentist examine the patient post incident: Yes ____ No ____

(Describe briefly what happened: (attach additional sheets as required)

Type of Injury: ____________________________________________________________________________________________

________________________________________________________________________________________________________

Suggested Treatment: _____________________________________________________________________________________

_______________________________________________________________________________________________________

Other Recommendations: __________________________________________________________________________________

________________________________________________________________________________________________________

(Signature of Person Reporting Incident)

(Signature of Office Manager/Receptionist)

Dental Office Incident Report