Application for General Anesthesia Permit - the Ohio State Dental ...

OHIO STATE DENTAL BOARDAPPLICATIONFOR A PERMIT TO BERESPONSIBLE FOR AND UTILIZE GENERAL ANESTHESIAAND/OR DEEP SEDATIONPlease Print or TypeRegistration Fee - $127 (Must be enclosed with application. Make check payable the Ohio StateDental Board).Inspection Fee - $400 (Must be enclosed with application. Make check payable the Ohio StateDental Board).Name: Date of Birth: / /Month Day YearOhio State Dental License No:Home Address:Primary Office of Facility Address:Additional Facility Address:Type of PracticeGeneral PracticeSpecialty Practice (Type)Phone No: ( )Phone No: ( )Phone No: ( )INITIAL ALL APPLICABLE CATEGORIES QUALIFYING APPLICANTFOR A GENERAL ANESTHESIA PERMIT. (ENCLOSE A COPY OFSUBSTANTIATING DOCUMENTS).1. Completed an approved, accredited post-doctoral training program which affordsappropriate training necessary to administer deep sedation and general anesthesia andmeets the objectives set forth in Part Two of the American dental association’s“Guidelines for Teaching the Comprehensive Control of Anxiety and Pain in Dentistry”.