Application for General Anesthesia Permit - the Ohio State Dental ...
Application for General Anesthesia Permit - the Ohio State Dental ... 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”.
2. Completed an approved Accreditation council for graduate medical education (ACGME)accredited post-doctoral training program in anesthesiology which affords appropriatetraining necessary to administer deep sedation and general anesthesia.3. Completed a minimum of one year advanced clinical training in anesthesiology from aJoint commission on accreditation of healthcare organization (JCAHO) accreditedinstitution that meets the objectives set forth in Part Two of the American dentalassociation’s “Guidelines for Teaching the Comprehensive Control of Anxiety and Painin Dentistry”.4. Has a properly equipped facility(s), whether fixed, mobile, or portable, for theadministration of general anesthesia or deep sedation in which the permit holder agreesto have available and utilize adequate monitoring, personnel, emergency equipment anddrugs as recommended in the American dental association’s “Guidelines for the Use ofConscious Sedation, Deep Sedation and General Anesthesia for Dentists” and/or theAmerican association of oral and maxillofacial surgeon’s “Office Anesthesia EvaluationManual”.5. Is currently certified in Advanced Cardiac Life Support or its age appropriate equivalent.6. Maintains a permanent address within the State of Ohio where he or she conductsbusiness pursuant to his or her Ohio State Dental License.EDUCATION AND TRAININGPre-Professional Education:School, College or University Degree(s) Dates of AttendanceDental Education:School, College or University Degree(s) Dates of AttendanceOther Professional Education:School, College or University Degree(s) Dates of AttendancePost-Doctoral Education:School, College or University Degree(s) Dates of AttendancePage 2
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2. Completed an approved Accreditation council <strong>for</strong> graduate medical education (ACGME)accredited post-doctoral training program in anes<strong>the</strong>siology which af<strong>for</strong>ds appropriatetraining necessary to administer deep sedation and general anes<strong>the</strong>sia.3. Completed a minimum of one year advanced clinical training in anes<strong>the</strong>siology from aJoint commission on accreditation of healthcare organization (JCAHO) accreditedinstitution that meets <strong>the</strong> objectives set <strong>for</strong>th in Part Two of <strong>the</strong> American dentalassociation’s “Guidelines <strong>for</strong> Teaching <strong>the</strong> Comprehensive Control of Anxiety and Painin Dentistry”.4. Has a properly equipped facility(s), whe<strong>the</strong>r fixed, mobile, or portable, <strong>for</strong> <strong>the</strong>administration of general anes<strong>the</strong>sia or deep sedation in which <strong>the</strong> permit holder agreesto have available and utilize adequate monitoring, personnel, emergency equipment anddrugs as recommended in <strong>the</strong> American dental association’s “Guidelines <strong>for</strong> <strong>the</strong> Use ofConscious Sedation, Deep Sedation and <strong>General</strong> <strong>Anes<strong>the</strong>sia</strong> <strong>for</strong> Dentists” and/or <strong>the</strong>American association of oral and maxillofacial surgeon’s “Office <strong>Anes<strong>the</strong>sia</strong> EvaluationManual”.5. Is currently certified in Advanced Cardiac Life Support or its age appropriate equivalent.6. Maintains a permanent address within <strong>the</strong> <strong>State</strong> of <strong>Ohio</strong> where he or she conductsbusiness pursuant to his or her <strong>Ohio</strong> <strong>State</strong> <strong>Dental</strong> License.EDUCATION AND TRAININGPre-Professional Education:School, College or University Degree(s) Dates of Attendance<strong>Dental</strong> Education:School, College or University Degree(s) Dates of AttendanceO<strong>the</strong>r Professional Education:School, College or University Degree(s) Dates of AttendancePost-Doctoral Education:School, College or University Degree(s) Dates of AttendancePage 2
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