Msig Dental Claim Form Page 2
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2MEDICAL REPORT
The Claimant must obtain at his/her own expense the medical report from his/her Medical Attendant.
TO BE COMPLETED BY ATTENDING DENTIST / SURGEON
Name of Patient
NRIC/Passport/BC Number*
Treatment date(s)
Date condition / injury was first diagnosed
(dd/mm/yyyy)
(dd/mm/yyyy)
Final Diagnosis (Based on ICD, 1975 Revision, WHO) of sickness* or extent of injury
ICD Code
What is the cause of the sickness / injury?
Tooth Chart
Treatments:
If yes, pls elaborate
Routine Preventative visit (including cleaning)
Yes
No
____________________________
Radiology
If yes, pls elaborate
i) bitewing intraoral
Yes
No
____________________________
ii) posterior/anterior/lateral skull
Yes
No
____________________________
iii) panoramic
Yes
No
____________________________
Fillings
If yes, pls mark on tooth chart
i) amalgam, 1-2 surfaces, permanent
Yes
No
ii) composite/resin, 1-2 surfaces, permanent
Yes
No
Extractions (non-surgical)
If yes, pls mark on tooth chart
i) simple extractions-erupted tooth or
Yes
No
exposed roots
ii) complicated extractions-tooth or root,
Yes
No
partially bony
Root Canal Treatment
If yes, pls mark on tooth chart
st
i) root canal (x-ray included)-1
treatment
Yes
No
nd
ii) root canal-2
treatment
Yes
No
*mark fillings by shading
rd
iii) root canal-3
treatment
Yes
No
*mark extraction with “X”
iv) therapeutic pulpotomy (excluding crown)
Yes
No
*mark root canal with “R”
How long had the patient been troubled by symptoms prior to the diagnosis?
In your medical opinion, how long do you think the condition existed prior to your diagnosis?
Did the patient have any symptoms prior to consulting you?
Yes
No
If Yes, please indicate the nature of the Symptoms and date Symptoms first started
:
(dd/mm/yyyy)
Are you the patient’s usual Dentist?
Yes
No
When did patient first consult you for this condition?
Nature and Date of Treatment rendered
(dd/mm/yyyy)
Were the teeth natural and free from decay, defects or prior restorations/appliances at the time of treatment?
Yes
No
If No, describe the condition of the teeth and the procedures or treatment rendered.
Date the procedures or treatment rendered
(dd/mm/yyyy)
Signature of Dentist
Name and Address of Clinic/Hospital
Name/Designation
Date
(dd/mm/yyyy)
*
Delete if not applicable
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