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State Form 46159 - Application For Permit To Administer Anesthesia And Sedation For Dentists

INDIANA STATE BOARD OF DENTISTRY

APPLICATION FOR PERMIT TO ADMINISTER

PROFESSIONAL LICENSING AGENCY

ANESTHESIA AND SEDATION FOR DENTISTS

State Form 46159 (R / 2-06)

Approved by State Board of Accounts, 2006

INSTRUCTIONS:

Please type or print.

FOR OFFICE USE ONLY

month, day, year

DO NOT WRITE ABOVE THIS LINE

APPLICANT INFORMATION

(Please check appropriate box below .)

(only)

(includes authorization to administer Light Parenteral Conscious Sedation)

(Last, first, middle, (maiden)

(number and street or rural route)

(month, day,

DENTAL DEGREE (S) GRANTED

month, day, year

EDUCATION AND TRAINING

(To be completed by applicants for General Anesthesia - Deep Sedation or Light Parenteral Conscious Sedation Permits)

General Anesthesia - Deep Sedation Permits / Advanced Education Program

month, year to month, year

month, day, year

Light Parenteral Conscious Sedation Permit / Training and Education

To be completed by applicants if: predoctoral training was obtained

month, year to month, year

To be completed by applicants if: postdoctoral training was obtained

month, year to month, year

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State Form 46159 - Application For Permit To Administer Anesthesia And Sedation For Dentists