Pupil Personal Accident Report (Page 2 of 4) in pdf

Pupil Personal Accident Report Page 2

Please describe fully the nature and extent of the injuries suffered by the injured pupil:

Does the injured pupil suffer from a pre-existing physical defect, infirmity or medical condition?:

Yes

If ‘Yes’ give details:

Name and address of doctor/dentist attending injured pupil:

Is the injured pupil the beneficiary of private healthcare insurance (e.g. VHI, Laya Healthcare, Irish Life Health, etc)

or medical card cover?

Yes

If 'Yes' please state the amount recoverable from the above source:

Have the injuries described prevented attendance at school?:

Yes

If ‘Yes’ between what dates: from:

to:

4. Medical certificate (if claim relates to dental please include full treatment plan form with this claim form)

To be completed by the doctor/dentist attending the injured pupil at the sole expense of the claimant. The cost of providing this certificate

is not covered under this policy.

Name of patient:

Age of patient:

Date of your first attendance on patient:

Are you still treating the patient?:

Yes

Full details of injuries suffered:

Are they consistent with the description of the accident as stated in section 4.?:

Yes

What treatment did you undertake/recommend to the patient?

Is the injury wholly due to the accident?:

Yes

Please state date of return to school:

Has the patient been confined to bed or house on your instruction?

Yes

If ‘Yes’ between what dates: From:

To:

If injury is continuing, please state the probable further duration of such total injury from this date:

If the patient has recovered please state date of recovery:

Signature of medical/dental practitioner

Date:

Address:

Qualification:

Pupil Personal Accident Report Page 2