Forms

w Complaint form - Board form used to file a complaint against a Dentist, Dental Hygienist or Denturist.

w Address Change Form for Dentists and Denturists

w Address Change Form for Dental Hygienists

w Adverse Occurrence Report - Form used to report any death or incident causing a patient temporary or permanent physical or mental injury occurring in a dental outpatient facility.

w Citizenship Form - Required statement of citizenship or alien status for all license applications and renewals.

w Renewal Continuing Education Affidavit - Statement of completed continuing education for Dentists, Dental Consultants, Dental Hygienists, and Restricted Permit Holders.  Retirees should call the office for renewal continuing education requirements.

w Lists and Labels - Information and Order Form for mailing lists and mailing labels.

Applications

w Dentist License Application by Credential - Application for Dentists licensed in other jurisdictions. Additional information and forms that may be required are listed below:

Requirements, instructions and exam information - Information for completing this application. 

Continuing Education Affidavit - Affidavit for licensure by credential for Dentists - may be required.

Affidavit to Practice - Affidavit for licensure by credential for dentists- may be required.

Malpractice Form - Required form if question 15 on the application is answered "yes".

Citizenship Form - Required statement of citizenship or alien status for all license applications.

Jurisprudence Examination - Information, fees and schedule for the required Jurisprudence Examination.

Dispensing For Profit - Registration and application and instructions for dentists who dispense drugs or devices for profit.

w Dentist License Application by Examination - Application for licensing Dentists by examination.   Additional information and forms that may be required are listed below:

Requirements, instructions and exam information - Information for completing this application.

Malpractice Form - Required form if question 15 on the application is answered "yes".

Citizenship Form - Required statement of citizenship or alien status for all license applications.

Jurisprudence Examination - Information, fees and schedule for the required Jurisprudence Examination.

Dispensing For Profit - Registration application and instructions for dentists who dispense drugs or devices for profit.

w Dental Hygienist License Application by Credential - Application for Dental Hygienists licensed in other jurisdictions. Additional information and forms that may be required are listed below:

Requirements, instructions and exam information - Information for completing this application. 

Affidavit to Practice - Affidavit for licensure by credential for Dental Hygienists - may be required.

Malpractice Form - Required form if question 15 on the application is answered "yes".

Continuing Education Affidavit - Affidavit for licensure by credential for Hygienists - may be required.

Citizenship Form - Required statement of citizenship or alien status for all license applications.

Jurisprudence Examination - Information, fees and schedule for the required Jurisprudence Examination.

w Dental Hygienists License Application by Examination - Application for licensing Dental Hygienists by examination. Additional information and forms that may be required are listed below:

Requirements. instructions and exam information - Information for completing this examination.  

Malpractice Form - Required form if question 15 on the application is answered "yes".

Citizenship Form - Required statement of citizenship or alien status for all license applications.

Jurisprudence Examination - Information, fees and schedule for the required Jurisprudence Examination.

w Dental Assistant Radiology Certification by Credential - Application and instructions for certification by credential. Additional required form:

Citizenship Form - Required statement of citizenship or alien status for all license applications.

w Affiliated Practice - Suggested forms and Instructions for reporting a affiliated practice relation between a Dentist and a Dental Hygienist

w Business Registration - Required by any business entity not exclusively owned by a licensee which provides dental services.

w Dental Hygienist Local Anesthesia and Nitrous Oxide Analgesia Certification

w Coronal Polishing Certification by Dental Assistants