State Form 46159 - Application For Permit To Administer Anesthesia And Sedation For Dentists Page 4

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S
EMERGENCY EQUIPMENT SAMPLE AFFIDAVIT
This is a sample.
general anesthesia deep sedation or light parenteral conscious sedation.
Photocopies of this sample will not be accepted by the board.
A
(number and street, city, state, and ZIP code)
M
P
L
NOTARY CERTIFICATE
E
month, day, year
month, day, year

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