Applications & Forms

All fees are non-refundable and are required to be sent WITH the application.  NO CASH WILL BE ACCEPTED.

• Applications for Dentist
• Applications for Dental Hygienist (Including Advanced Procedures)
• New Dental Assistant Applications
• Renewal Forms 

• Complaint Process and Form
• Name Change/Copy Request
• Verification of Licensure Request Form
• Placing my License in In-Active or Retirement Status
• Professional Entity Application
• Dispensing Permit Form
  (View the Controlled substance log example)
• Address List Request Form
• Expanded Function Request Form

• Special Volunteer License Application
• Open Records Request Form

• New Dental Lab Application for Dentist owned Lab
• New Dental Lab Application for Non-Dentist owned Lab
• Dental Lab work Authorization Form
• Mobile Dental Lab or Clinic Application

• Facility Applications - There is a $100 fee for this application and it does require an inspection before a permit can be issued.  Please read the following rules to ensure you understand the requirements for each.  There is only one application for all facility types, the form with the checklist is below:
• Facility Anesthesia Application for Pediatric Conscious Sedation - 195:20-1-3.1(d)
• Facility Anesthesia Application for Parenteral Conscious Sedation - 195:20-1-4(d)
• Facility Anesthesia Application for General Anesthesia - 195:20-1-5(d)
  •     Facility Application      

Please note the required CE for General Anesthesia Facility Permits:

(f)    Direct supervision of a Certified Registered Nurse Anesthetist (CRNA). A dentist is permitted to directly supervise the administration of general anesthesia (including deep sedation) to patients by a CRNA provided that the following requirements are satisfied:

(1)                   Current certification in Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS) or Pediatric “ Advanced Life Support (PALS) by the American Heart Association.

(2)                   Complete every three (3) years at least eighteen (18) hours of courses related to the administration of anesthesia, sedation or medical emergencies in the dental office. Hours accrued completing certification or re-certification in BLS and ACLS or PALS shall be accepted towards completion of this eighteen (18) hour requirement.

(3)                   Hold a valid facility permit as described in 195:20-1- 4(d).

• Provider Applications - There is a $100 with these applications that must be included when submitted to the Board office.  These require an inspection before a permit can be issued.  Please read the following rules to ensure you understand the requirements for each:
  
• Provider Anesthesia Application for Pediatric Conscious Sedation - 195:20-1-3.1
• Provider Anesthesia Application for Parenteral Conscious Sedation - 195:20-1-4
• Provider Anesthesia Application for General Anesthesia - 195:20-1-5