CONFIDENTIAL

If you suspect that an adverse incident has occurred relating to orthodontic treatment, please complete this form below. Don’t be put off if some details are not known.

    *All fields are mandatory

    Patient Details

    Patient Identifier* (Your Practice / Hosp Ref No. or Initials)

    Sex*
    MaleFemale

    Age* (At time of incident)

    Adverse incident* (Please describe the incident(s) and any treatment given):

    Please indicate by choosing a category of adverse incident that occurred

    Other reaction
    YesNo

    Do you consider the event to be serious*
    YesNo

    If yes, please indicate why the incident is considered to be serious (please tick all that apply):

    Reporter Details

    Position*

    Name*

    Address Line 1*

    Address Line 2

    Town*

    County

    Post Code*

    Country

    Email*

    Telephone Number*