Forms and Applications

Forms

• Complaint form - Board form used to file a complaint against a Dentist, Dental Hygienist or Denturist.
• Address Change Form for Dentists and Denturists
• Address Change Form for Dental Hygienists
• 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.
• Citizenship Form - Required statement of citizenship or alien status for all license applications and renewals.
• 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.
• Lists and Labels - Information and Order Form for mailing lists and mailing labels.

Applications

• 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.
• 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.
• 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.
• 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.
• 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.

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

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

• Dental Hygienist Local Anesthesia and Nitrous Oxide Analgesia Certification

• Coronal Polishing Certification by Dental Assistan